sportEX Medicine Journal Issue 59 - January 2014

ISSUE 59 Jan 2014 ISSN 1471-8138

promoting

excellence in

highlights

sports

n latest research news n research analysis n psychology of sports injuries

medicine n hamstring injuries in football

n patellofemoral taping n management of patella dislocation

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contents January 2014 issue 59

Welcome

publisher ToR DAvIES BSc (Hons) tor@sportex.net art editor DEBBIE ASHER debbie@sportex.net sub editor AlISon SlEIGH Journal watch BoB BRAMAH subscriptions & advertising support@sportex.net +44 (0)845 652 1906 coMMISSIonInG EDIToRS Brad Hiskins - Australia & nZ Whitney lowe - USA & canada Humphrey Bacchus - UK & Europe Glenn Withers - Worldwide Dr Marco cardinale - Worldwide Dr Thien Dang Tan - USA & canada Joseph Brence, DPT, coMT, FAAoMPT, DAc TEcHnIcAl ADvISoRS Steve Aspinall Bob Bramah Paula clayton Stuart Hinds Rob Granter Michael nichol Joan Watt Dr Greg Whyte

jan 2014

When I published the first issue of sportEX medicine, 14 years ago, the mission was simple; to produce a journal that bridged the gap between “the findings and the doing”, or more specifically turning the research into practice.

We’ve had our fair share of academics turn their noses up at sportEX for not being a pure research journal. In fact we’ve lost out on a couple of professional association subscription deals, because the powers that be believed research journals were more important to their members, than something which translated that research into information that helped them do their jobs more effectively and with less mental effort (I wonder how many took the time to consult the people paying the member subs about what they would prefer?).

But the tide is turning because the pressure to do more with less, both time and money, is unrelenting. Research is fundamentally and critically important, we all know that, but it’s what you do with it that matters. This is why we’re focusing on forging alliances with like-minded people such as Joseph Brence, our US research reviewer, who from the April issue onwards will become a commissioning editor, with his own dedicated section. If you are like-minded and have a access to a pool of practitioners committed to turning evidence into practice, and are interested in a similar arrangement then get in touch (tor@sportex.net).

BSc (BASRaT), MSc McSP, MSMA MSc, FA Dip, Mast STT Dip SST Dip SST BSc (BASRaT) McSP, MSMA PhD, BSc (Hons)

In the meantime enjoy the issue. is published by Centor publishing Ltd 88 nelson road Wimbledon, sW19 1HX Tel: +44 (0)845 652 1906 fax: +44 (0)845 652 1907 www.sportex.net oTHer TiTLes in THe sporTeX range

Tor davies, physio-turned publisher and sportEX founder tor@sportex.net

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best pra sporteX dynamics manua ctice - ISSn 1744-9383 theralp y Written specifically for professionals working with a wide variety of athletes and sports people to help them get the most out of their athletic performance - personal annual subscription from £54, practice subscription from £94 ing

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THe environmenT sportEX is printed in the UK by cambrian Printers ltd, award-winning colour printing specialists, independently audited to ISo 14001 and EMAS environmental standards. sportEX is printed on paper from FSc certified forests using vegetable-based inks, chemical free plates and presses running alcohol free. It is also mailed in biodegradable polybags.

hts

ConTenTs

4 Journal watch 8 research analysis 10 psychology of sports injury The latest key research

Two detailed reviews on turning evidence into practice Getting athletes back to play

16 Hamstring injuries in football 23 Taping: evidence or hype?

28 Case study Part 1: Assessment, diagnosis and prognosis

The treatment of patellofemoral pain with taping

Management of acute patella dislocation

To find ouT more abouT sporTeX visiT

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exercise for lower limB osTeoarThriTis: sysTemaTic reView incorporaTing Trial sequenTial analysis and neTworK meTaanalysis. uthman oa, Van der windt da, et al. BmJ 2013;347:f5555 Nine electronic databases were searched looking for randomised controlled trials comparing exercise interventions with each other or with no exercise control for adults with knee or hip osteoarthritis. Sixty were found (44 knee, two hip, 14 mixed) covering 12 exercise interventions and with 8218 patients. There was significant benefit of exercise interventions over no exercise control. For pain relief, strengthening, flexibility plus strengthening, flexibility plus strengthening plus aerobic, aquatic strengthening, and aquatic strengthening plus flexibility, exercises were significantly more effective than no exercise control. A combined

intervention of strengthening, flexibility, and aerobic exercise was significantly more effective than no exercise control for improving limitation in function.

sportEX comment The evidence mountain grows yet taller with research suggesting that we are made to move and we should do so as much as possible even if bits are wearing out. The authors of the latest pebble to lodge on the top are so confident of their findings they state that further trials are unlikely to overturn this result and they used a ‘Bayesian network meta-analysis’ to prove it, so it must be right.

The effec effecTs of Two TherapeuTic paTellofemoral Taping Techniques on sTrengTh, endurance, and pain responses. osorio Ja, J Vairo gl, et al. physical Therapy in sport 2013;14(4):199–206 Twenty physically active patellofemoral pain syndrome (PFPS) patients were tested for baseline isokinetic strength, endurance, and perceived pain.

Then they were taped up using either a Spider® or McConnell protocols. Taping improved clinical measurements but there were no differences between the two techniques.

sportEX Stick the tape on any old way and show your patient a picture of their favourite athlete all taped up. You will get great results.

are JoinT inJury, sporT acTiViTy, physical acTiViTy, oBesiTy, or occupaTional acTiViTies predicTors for osTeoarThriTis? a sysTemaTic reView. richmond sa, fukuchi rK, et al. Journal of orthopaedic & sports physical Therapy 2013;43(8):515–524 Twelve electronic databases were systematically reviewed. The studies selected met the following criteria: (1) original data; (2) joint injury, sport activity, physical activity, overweight/obesity, and/or occupational activity investigated as risk factors; (3) outcomes included OA (hip, knee, and/or ankle); and (4) analytic component of study design.

The data extracted included study design, years of follow-up, study population, OA definition, risk factors, and results.

The findings were that joint injury, obesity, and occupational activity were associated with an increased risk of OA of the knee and hip. Sport and physical activity produced inconsistent findings. There is a little research examining risk factors associated with ankle OA.

sportEX Comment OA affects up to 10% of men and 18% of women over 60 years of age. The jury is out on sport causing OA unless you happen to get a joint injury or be a tad on the large side. Trouble is that if you follow some measures of obesity, members of national rugby teams fall into the category. I don’t suppose the joints care if the load they carry is muscle mass or lard, it still puts them under strain.

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JOURNAL WATCH

Journal watch anaTomy of The anTerolaTeral ligamenT of The Knee. claes s, Vereecke s et al. Journal of anatomy 2013;223(4):321–328 Way back in 1879, a French surgeon described the existence of a ‘pearly, resistant, fibrous band’ at the anterolateral aspect of the human knee. Since then a similar structure as variously been described as ‘(mid-third) lateral capsular ligament’, ‘capsulo-osseous layer of the iliotibial band’ or ‘anterolateral ligament’, and no clear anatomical description has yet been provided. So this group of surgeons investigated 41 unpaired, human cadaveric knees and found that in all but one of them (97%), there was a well-defined ligamentous structure, clearly distinguishable from the anterolateral joint capsule. They

are now calling this structure the anterolateral ligament (ALL). The origin of the ALL was situated at the lateral femoral epicondyle, slightly anterior to the origin of the lateral collateral ligament and there are connecting fibres between the two. The ALL runs obliquely to the anterolateral aspect of the proximal tibia inserting midway between Gerdy’s tubercle and the tip of the fibular head. It has attachments to the lateral meniscus. It is separate from the iliotibial band. Given its structure and anatomic location, the ALL is hypothesised to control internal tibial rotation and thus to affect the pivot shift phenomenon.

sportEX comment This study was announced in a media frenzy with the popular press claiming a major breakthrough and a reason why ‘knees give way’. Why after 500 years of formal anatomy study has this not been ‘discovered before’? Maybe instead of being cynical we should reflect on the human body and the fact that if it is truly a new discovery it’s amazing that after those 500 years we are still finding out new things. The clinical relevance of this may be that whether it is an all new structure or a thickening of the joint capsule (and this study suggests the former) the fact that it is attached to the lateral meniscus may be of interest.

o oxford grading scale Vs manomeTer for assessmenT of pelVic floor s sTrengTh in nulliparous sporTs sTudenTs. da roza T, mascarenhas T, et al. physiotherapy 2013;99(3):207–211 ‘Nullparity’ is the state of not having had kids (although there is controversy in the definition about pregnancies terminated under 24 weeks). ‘Manometry’ is about measuring pressure. Why do medics not just say so without using fancy words?

Forty-three female sports students (mean age 21) who had not given birth had their pelvic floor muscle contractions measured using the Oxford Scale and an instrument. There was a significant moderate correlation between the two. Mean maximal strength for the entire group was 70.4cm H2O. Out of 43 subjects, 37% (n = 16) demonstrated signs of incontinence. Using the instrument there was no significant difference in vaginal resting pressure or peak pressure between the continent and incontinent groups.

sportEX comment The results regarding measurement reported here are not the most important factor for those of us involved in sport.

We should be concerned that, out of 43 female sports students who had never given birth and who performed physical activity at a high level, 16 classed themselves as incontinent (5 urge incontinence, 9 stress incontinence and 1 mixed). They also reported that incidents were not uncommon. Is this an unreported issue we should be investigating further?

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ouTcomes of osTeopaThic manual TreaTmenT for chronic low BacK pain according To Baseline pain seVeriTy. licciardone Jc, Kearns cm, minotti de. manual Therapy 2013;18(6)533–540 This study assessed 269 (59%) patients reporting low baseline pain severity (LBPS) and 186 (41%) reporting high baseline pain severity (HBPS). They received six osteopathic manual treatment (OMT) sessions over 8 weeks. This basically means graded manual therapy.

Outcomes were assessed at week 12. The primary outcome was substantial low back pain (LBP) improvement (>50% pain reduction). The Roland–Morris Disability Questionnaire (RMDQ) and eight other secondary outcomes were also studied. There was substantial LBP improvement in patients with HBPS plus improvement in back-specific functioning on the RMDQ. OMT was consistently associated with benefits in all other secondary outcomes in patients with HBPS, although the statistical significance and clinical relevance of results varied.

sportEX comment As the authors point out, the large effect size for OMT in providing substantial pain reduction in patients with chronic LBP was associated with clinically important improvement in back-specific functioning and therefore may be a treatment choice before more invasive (and costly) interventions like surgery are undertaken.

d does effecTiVeness of exercise Therapy and moBilisaTion Techniques offer guidance for The TreaTmenT of laTeral T and medial epicondyliTis? a sysTemaTic reView. hoogvliet p, randsdorp ms, et al. British Journal of sports medicine 2013;47:1112–1119 All the usual databases were searched to identify randomised clinical trials (RCTs) and systematic reviews. This turned up one review and 12 RCTs, all studying lateral epicondylitis. Stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist were evaluated. A bestevidence synthesis was used to summarise the results.

They found moderate evidence for the short-term effectiveness of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence was found for short-term and mid-term effectiveness for the manipulation of the cervical and thoracic spine as an add-on therapy to concentric and eccentric

stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found.

sportEX comment These sorts of study remind us of a playground fight.

Stretch v ultrasound, manipulation v mobilisation. My Dad is bigger than your Dad! It doesn’t really help clinically and you can’t pool the results to get a bit of statistical clout because the methodology varies between papers. It is time that therapy organisations published a methodological guide to standardise research. That way the numbers might add up and mean something. Smart physical therapists, by the way, will try all of the modalities.

a piloT sTudy To inVesTigaTe The shorT-Term effecTs of specific sofT Tissue massage on upper cerVical moVemenT impairmenT in paTienTs wiTh cerVicogenic headache. hopper d, yogita B. Journal of manual & manipulative Therapy 2013;21(1):18–23 This study comes from the premises that upper cervical movement impairment and muscle dysfunction have been identified as core components of cervicogenic headache (CGH) and that if you improved the movement there may be benefits in reducing the headache. Eight subjects (mean age 28.1 years) with published criteria of CGH (mean history of headache for 7.1 years) were investigated. Range of rotation of the upper cervical spine to the left and right was determined by the flexion–rotation test. Movement was assessed in three phases: pre-intervention, intervention, and post-intervention. The specific soft tissue massage intervention consisted of an 8min soft tissue massage to the cervical muscles bilaterally. The results were a significant improvement in range of rotation to the left and right after the first, second, but not the third intervention, from an average range of 27.5° at baseline to 45.9° at the third treatment session. After the 2-week post-intervention phase, range of motion remained stable without decline, and was considered full range.

sportEX comment Sports massage is good. That’s all you need to know really. It can dramatically improve range of motion. Whether it does anything for the headache is a question for another day.

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JOURNAL WATCH

in inTeresT of rehaBiliTaTion in healing and preVenTing recurrence of anKle sprains. pre guillodoa y, simona T, et al. annals of physical and rehabilitation medicine 2013;56(7– 8):503–514 One hundred and eleven ankle sprain patients were originally selected. The diagnosing physician in an emergency room was free to prescribe, or not, further investigations. He/ she prescribed systematically to patients a RICE (rest, ice, compression, elevation) protocol, put on an ankle brace, and gave a prescription of standardised rehabilitation. One year on, 21 patients were excluded for lack of response leaving 90 (56 male, 34 female), mean age 31.4 ± 1.6 years (range 15–55) at the time of initial trauma. They were asked to fill in a Foot and Ankle Outcome Score (FAOS) questionnaire, the level of recovery in comparison with pre-trauma status; and whether a sprain recurrence had occurred in this ankle.

The initial diagnoses of the survivors was 16 mild sprains (17.8%), 56 medium sprains (62.2%) and 18 severe sprains (20%). Compliance rates were that 73 out of the 90 (81.1%) undertook the prescribed rehabilitation. Compliance by method of injury was recorded with 31/44 (70.5%) having what was described as accidents of everyday life, 25/27 (92.6%) sports accidents, 17/19 work-related injuries (89.5%).

Of the 73 who complied, 36 (49.3%) consider their recovery to be total (FAOS score 100), 29 (39.7%) have sequelae, 6 (8.2%) had a sprain recurrence, 1 (1.4%) presented with a bimalleolar fracture and 1 had ankle surgery because of persistent pain. Of the 17 patients who did not follow the rehab protocol, 8 (47%) considered they are completely healed, 6 (35.3%) have sequelae, 2 (11.8%) had a sprain recurrence, and 1 (5.9%) a bimalleolar fracture. Of the 44 healed patients, seven had initially a mild sprain, 30 a moderate sprain, and seven had a severe sprain.

Statistically what all this means is that there was no significant relationship between rehabilitation and no recurrence nor between rehabilitation and full recovery of the ankle.

The rehab prescription was two sessions a week for

Time-motion analyses were performed using global positioning systems from 6 elite National Rugby League and 11 junior elite National Youth Competition players from 45 matches. A standardised 5-point technical coding criteria was used to qualitatively assess skill involvements during match-play. The distance travelled in the 0–5 and 40–45min period were significantly higher compared to the 30–35, 35–40, 70–75 and 75–80min

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two weeks during which the patients received drainage and circulatory massage, analgesic and anti-inflammatory physiotherapy. Then 12 sessions, on the basis of two or three sessions a week during which they got mobilisation of the ankle to increase ROM, muscular strengthening and proprioception. The ankle braces stayed on for 5–6 weeks depending on progress.

sportEX comment This is a worrying outcome for physical therapy. If roughly the same percentage feel they have recovered with a rehab protocol as the ones who didn’t follow a programme then fund holders are going to be asking themselves why they need to pay for a physio. We note also that it is the sporty ones with the highest rehab rate.

Is this because the sporty types have greater determination to return to play? There are positives to be taken however.

The mean delay before the start of rehabilitation was 11.29 days for the ones that didn’t have a recurrence, and 25 days for the ones that did which suggests early intervention is better and you can argue that that is where the need for a physio is paramount. We also note that the authors feel their study is limited by the small size of the nonrehabilitated group. This, friends, is what evidence-based medicine research has led us to; complaining that people get better and muck up the stats!

maTch-relaTed faTigue reduces physical and Technical performance during eliTe rugBy league maTch-play: a case sTudy. Kemptona T, siroticb ac, et al.

Journal of sports sciences 2013;31(16):1770–1780 periods. Skill rating and involvements were higher in the 0–5 and 40–45min compared to 70–75 and 75–80min periods. There was no significant difference in the number of physical collisions between the 5min periods.

Following the players peak 5min bout of exercise intensity there were reductions in distance, quality of skill

involvements, number of involvements and collisions.

sportEX comment This proves what we know. Get tired and you don’t play as well. And more importantly, although it is not covered in this piece of work, that is also when the injuries come.

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Work-related injuries affect almost 500,000 individuals annually in the United States, and estimated direct and indirect costs range from 45 to 215 billion dollars (1). Work-related injuries can lead to the development of chronic pain as well as changes in societal status and psychological variables such as depression. Research has suggested that one out of every three individuals who suffer from chronic pain also suffer from depression.

Elevated levels of depression are associated with an increased risk for a poor response to physical therapy and also with elevated levels of pain and disability.

the study A recent paper (2) examined the effects of physical therapy on depressive symptoms in individuals with work-related musculoskeletal injuries.

Patients met the following criteria: were between the ages of 18 and 65; had sustained a work-related, musculoskeletal neck or back injury that was in the subacute phase of recovery (3–12 weeks since onset); were not currently working; were receiving benefits from Worker’s Compensation. The participants also had to have clinically relevant levels of depression (measured on a Beck Depression Inventory of 14 or higher) and had to state that they were not being treated for depression throughout their course of physical therapy.

The enrolled participants completed self-report questionnaires at treatment onset, mid-treatment, and after completing 7 weeks of treatment. They also completed a phone interview 1 year after treatment onset. The patients rated pain intensity, on a numeric pain scale; symptoms of depression, on a Beck Depression Inventory II; pain catastrophising, on a Pain Catastrophising Scale; fear of movement, on a Tampa Scale for Kinesiophobia; and pain self-efficacy, on the Pain Self-Efficacy Questionnaire. The 1-year follow-up phone interview determined the patients’ return-to-work status and level of pain. The participants completed a course of 7 weeks of physical therapy treatment interventions, which were not restricted by the researchers (but all were consistent with clinical practice guidelines in the treatment of subacute musculoskeletal injuries). I applaud the researchers for this decision because it makes the outcomes of the study more clinically relevant and helps maintain a level of external validity.

The researchers were able to enrol 235 participants, although only 124 met the criteria 8

Our regular research reviewer, physical therapist Joseph Brence, analyses studies looking into (1) whether physical therapy can help reduce depression in people suffering work-related injuries, and (2) the benefits of the therapeutic bond between patient and therapist.

Physical theraPy may assist in recovery from dePression in injured workers for the initial levels of depression. Out of these, 18 did not complete follow-up data and the results were determined from a group of 106.

The outcomes demonstrated that depressive symptoms resolved in 40% of patients who entered into a physical therapy programme following a work-related accident.

This outcome is not unusual because of the neurological and hormonal changes that we know to occur with exercise. The authors further reported that a reduction in depressive symptoms was related to a decrease in pain and disability at the 1-year follow-up. For those who did not get better, it appears that combined elevated levels of depression and pain catastrophising before treatment predicted the persistence of depressive symptoms after treatment. Depressive symptoms posttreatment were also predicted by a lack of improvement in a combination of depressive symptoms and pain self-efficacy at midtreatment.

what does this mean?

These findings indicate that physical therapy can have a profound effect in decreasing depressive symptoms in a subgroup of individuals. The authors even suggest that, in certain instances, we may want to include a reduction in depression as a realistic and important goal of treatment. I believe this study gives us more prognostic tools to predict those who are likely, as well as least likely, to respond to physical therapy treatment.

incorPorate screening for dePression into your Practice As a physical therapist, we do not make a

clinical diagnosis of depression but it is important that we screen for it. And screening is really easy. I use the Patient Health Questionnaire-2 which is simply two questions that we can ask a patient to see if they would be appropriate for a medical referral for depression (3). I have included it below: Question: In the past 2 weeks, how often have you been bothered by the following problems: 1. Little interest or pleasure in doing things (Not at all = 0, Several days = 1, More than half the days = 2, Nearly every day = 3) 2. Feeling down, depressed or hopeless (Not at all = 0, Several days = 1, More than half the days = 2, Nearly every day = 3) A score of 3 has a sensitivity of 82% and specificity of 90% for a major depressive episode, and sensitivity of 62% and specificity of 95% for any depressive disorder.

References 1. Dunning KK, Davis KG, et al. Costs by industry and diagnosis among musculoskeletal claims in state workers compensation system: 1999-2004.

American Journal of Industrial Medicine 2010:53;276–284 2. Wideman TH, Scott W, et al. Recovery from depressive symptoms over the course of physical therapy: a prospective cohort study of individuals with work-related orthopaedic injuries and symptoms of depression.

Journal of Orthopaedic and Sports Physical Therapy 2012:42;957–967 3. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care 2003:41;1284-1292. sportEX medicine 2013;59(January):08-09

ReSeARch RevIewS

By josePh Brence dPt, comt, dac The profound effect that clinical interactions have on our patients is often downplayed by the modern clinician. We often attribute clinical success to the tools we use and how they improve mobility, range of movement (ROM) or strength. But how often do we consider the effects that are elicited when we simply interact with our patients? A recent article looked at this very notion and attempted to determine if the interaction between physical therapist and patient (those with chronic low back pain) is predictive over outcomes (1).

The authors of this study designed a retrospective observational study, which was nested in a randomisedclinical trial investigating the outcomes of three common interventions for chronic low back pain (CLBP): general exercises, spinal manipulative therapy and motor control exercises.

The emphasis of this study was to investigate the effects of the therapeutic alliance. The researchers defined therapeutic alliance as ‘the sense of collaboration, warmth and support between the client and therapist’. They reported that there are three main components to this concept, as defined by Bordin (2). First, the therapist and patient agree upon the goals. Second, the therapist and patient agree upon the interventions.

Third, there is an affective bond between therapist and patient. As a physical therapist, I believe this concept, at face value, makes sense. But do we always consider all three variables or do our opinions and beliefs get in the way? And if we become too operative (ie. determine what is best for the patient versus interacting with their goals and beliefs), what exactly happens to outcomes? These are things to reflect on.

The participants in this study were randomised to one of three interventional groups (182 total participants included). Each participant then attended twelve sessions over an 8-week period, at which point several variables were measured. Primary outcomes of patient-specific function were measured on a Patient Specific www.sportEX.net

don’t ignore the imPortance of the theraPeutic alliance

Functional Scale (PFPS) and the global perceived effect of treatment, on a Global Perceived Effect Scale (GPE).

Secondary outcomes of pain and disability were measured on the Visual Analogue Scale (VAS) and Roland– Morris Disability Questionnaire (RMDQ) respectively. Therapeutic alliance was lastly measured (baseline at the 2nd visit) on the Working Alliance Theory of Change Inventory (WATOCI) (3).

The authors found that positive measures of therapeutic alliance were associated with improvements of outcomes in all three groups of individuals with CLBP. They actually determined that the therapeutic alliance predicted all of the final clinical outcomes and higher levels of therapeutic alliance were associated with greater improvements. Among all the clinical outcomes measured,

therapeutic alliance was most strongly associated with disability.

Overall, this study reinforces the concept that we are physical therapists.

We need to remember that the way we interact with our patients can have a profound effect on their recovery. We must keep in mind that outcomes may be due to more than we think.

References 1. Ferraira PH, Ferraira ML, et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical Therapy 2013;93:470–478 2. Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice 1979;16:252–260 3. Horvath AO, Greenberg LS. Development and validation of the working alliance inventory. Journal of counseling Psychology 1989;36:223–233.

ThE auThoR Joseph Brence (PT, DPT, FaaoMPT, CoMT, DaC) is a Physical Therapist and fellow of the american academy of orthopedic Manual Physical Therapists, from Pittsburgh, uSa. he has just been appointed a commissioning editor for sportEX. Joseph’s primary clinical interests involve developing a better understanding of the neuromatrix and determining how it applies to physical therapy practice. he is involved in a wide range of clinical research projects investigating the mechanisms of how manual therapy may be beneficial in the treatment of pain.

Joseph is also an editorial board member for the aPTa consumer-driven website, moveforwardpt.com, runs the blog www.forwardthinkingpt.com and acts as the Vice President of operations for the NXTGen Institute, which offers post-doctoral educational programs for physical therapists.

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Risk, Response and RecoveRy PsyCHOLOgy OF sPORTs InjURy

BY Dale ForsDYke Msc, MsMa, MssT

InTroDucTIon The overall incidence of sports injury is rising leading to the common belief within sport that there two types of athlete – those that have suffered a serious injury and those that have not suffered one yet (1). One former England Rugby Union player summed up his experience as, “Players are only one training session away from a career ending injury”. This raises the issue of implementing effective injury prevention strategies and the need to manage sports injuries using best practice.

Due to the various demands on practitioners it is very easy to ignore the holistic nature of sports injury prevention and rehabilitation. According to Kolt (2) sport injury rehabilitation has developed into being a multifaceted process, and means that practitioners working with injured athletes should endeavour to appreciate both the physical and psychological to be truly effective. To put this into context there is a natural assumption that physical and psychological recovery from sports injury takes place within the same time frames when they frequently do not (3). This means that athletes may well be returning to sport competition when they are physically, but not 10

The idea of a holistic approach to sports injury prevention and recovery is nothing new. This article provides a review of the psychology of sports injury risk, response and recovery. It is hoped this will provoke thought and raise awareness about the psychology of sports injury leading to more effective preventative strategies being adopted and more successful rehabilitation outcomes from sports injury. psychologically, ready to return and may this contribute to an overall risk of re-injury.

rIsk oF sporTs InjurY What if an athlete’s risk of sports injury could be predicted by their personality type? It’s very much a philosophical argument about how much the physical versus psychological factors contribute to sports injury.

However, both theoretically and empirically there does seem to be key psychological determinants that increase an athlete’s risk of sports injury. The established Williams and Anderson Model (4) suggests a number of key psychological factors contribute to an athlete’s risk of injury.

It is thought that an athlete’s history of stressors, personality and coping resources all come together to affect their cognitive appraisal of a particular incident leading to adverse stress response (eg. narrowed attention focus, greater distractibility, and higher levels of muscle tension) and subsequently a sports injury (see Fig. 1). History

of stressors includes those that are sport specific, injury history and importantly the ‘away from sport’ life stressors, eg. significant change such as relationship breakdown and moving home. At-risk personality variables include poor self-esteem, high anxiety levels, neuroticism, risk taking and hardiness. Coping resources include having appropriate social support, sleep, coping type, diet, education/ awareness, and relaxation skills. An example to illustrate the model could be a Rugby League player who has just become a first time parent and has high levels of performance anxiety. In the 75th minute of an important game when required to tackle the opponent’s

ATHLETEs MAy WELL bE RETURnIng TO sPORT COMPETITIOn WHEn THEy ARE PHysICALLy bUT nOT PsyCHOLOgICALLy READy sportEX medicine 2014;59(January):10-15

evidence infoRmed pRactice

best player, the player’s psychological attributes would combine to potentially affect his skills execution and decision making leading to a poor tackling technique contributing to potential head injury.

There is consistent empirical evidence that would suggest support for this model and the premise that high levels of life stress and anxiety contribute to sport injury. Maddison and Prapavessis (5) conducted a study of 470 rugby players in new Zealand and found significant relationships between low levels of social support, high level of anxiety, ineffective coping strategies and both injury rate and severity. In a study using 48 swedish soccer players, Ivarsson and johnson (6) found that over 3 months the players injured during this period reported high baseline measures of life stress, anxiety and ineffective coping strategies compared with the non-injured players. According to the evidence base, understanding the personogenic make-up of the athletes you work with and being aware of the external stressors they are facing on a day-to-day basis may prove beneficial in reducing rate and impact of sports injury (box 1)(7).

malingering or poor adherence (9).

These behaviours can, therefore, delay physical healing such as an athlete not following advice and icing the injury or maintaining optimal loading.

Conversely an over motivated and frustrated athlete (if I do more it means I will recover faster) may delay physical healing by doing too much contributing to further damaging tissue in a fragile healing area.

There is a clear continuum of psychological response to sustaining a sports injury ranging from mild to severe with some authors reporting frequent clinically meaningful psychological distress, eating disorders, use of banned ergogenic aids and even suicidal tendencies amongst injured athletes (9,10). When working with injured athletes there is a necessity for the practitioner to be able to distinguish between the ‘normal’ psychosocial responses to sports injury (eg. yellow flags) and ‘severe’ responses (eg. orange flags) which would require referral to another healthcare professional such as a g.P. There are many robust questionnaires that can be used as outcome

response To sporTs InjurY As practitioners we are constantly challenged to manage the psychological fall-out from sustaining sports injury. According to both theory and empirical evidence we should assume that, to an athlete, getting injured is a significant life event and that this affects the athlete’s interlinking emotions, cognitions, and behaviours (8). Emotional responses are about what we feel, cognitive about how we think, and behaviour about what we do. These responses can be adaptive, and facilitate recovery, or maladaptive, ultimately hindering recovery. For example it is common for an injured athlete to question their competency (I can’t do it anymore) suffer with high levels of re-injury anxiety (I won’t do this exercise as it will only make it worse) and question their identity (if I can’t train and compete what am I supposed to do now?) which can lead to maladaptive behaviour such as www.sportEX.net

Personality

poTenTIallY sTressFul aThleTIc sITuaTIon

Cognitive appraisals

WE sHOULD AssUME THAT, TO An ATHLETE, gETTIng InjURED Is A sIgnIFICAnT LIFE EvEnT measures of psychological response to injury that may prove beneficial when working with injured athletes (eg. Re-injury Anxiety Inventory, sport Injury Anxiety scale, and sports Injury Rehabilitation Adherence scale). stage-based approaches such as the grief Response Model (11) have been applied to describe the emotional transition through sports injury recovery. This model originates from individuals coming to terms with a diagnosis of terminal illness and suggests the stages of denial, anger, bargaining, depression are ultimately progressed through until acceptance of the injury and a readiness to embrace rehabilitative support. Table 1 highlights how this model can be applied to sports injury recovery with associated thoughts and behaviours.

There has been criticism of this model when applied to injured athletic

History of stressors

Coping resources

sTress response Physiological/ attention changes

InjurY

Interventions

Figure 1: Adapted stress and injury model [Adapted from Williams and Anderson, 1998 (4)]

Box 1. pracTITIoner TIps For prevenTIng InjurY 1. Maintain open and continuous communication about sport and life stresses 2. Ask athletes to keep stress logs/diaries 3. be aware of particularly stressful points in the season and those that do not seem themselves during this period 4. Raise awareness of the link between high level of stress/anxiety and injury risk 5. screen athletes for anxiety based personality traits and intervene with stress management techniques.

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populations but a sense of loss and grief with emotions of frustration, anger and depression is commonly reported in the research, though not a predictive order (12). In a study by Carson and Polman (13) a contrasting sequential movement through the emotions of shock, depression, relief, encouragement, and confidence building was found from interviewing a professional Rugby Union player throughout anterior cruciate ligament rehabilitation requiring surgical intervention.

As a result of some of limitations in stage-based approaches in explaining psychological responses to sports injury, cognitive appraisal approaches have developed a reputation for being more credible. Cognitive appraisals are processes through which potentially stressful situations (eg. sustaining an injury) are assessed as being

TaBle 1. grIeF response MoDel conTexTualIseD To sporTs InjurY response [Adapted from Kübler-Ross, 1969 (11)] grief response stage

associated thoughts

associated behaviours

Denial

I refuse to accept I’m injured I can play my way through this, it won’t stop me

Continue to take part despite pain and loss of function

anger

I blame the opposition they were targeting me It’s the fault of the coach for his tactics

Aggressive behaviour storming away

Bargaining

If I do more I will recover faster Coach, I can play. The therapist doesn’t understand when he says I can’t

Failure to follow advice Danger of over motivation

Depression

This injury isn’t getting better at all Why should I even bother doing these exercises?

Withdrawal from the team general lethargy

I need to take all advice on board and act I know I am injured but can come back fitter and better than before

Compliance with rehabilitation plan

acceptance

pre-InjurY FacTors Personality

History of stressors

Coping resources

PsT interventions

stress response

sport injuries

response To sporT InjurY anD rehaBIlITaTIon process personal FacTors Injury

n n n n

History severity Type Perceived cause

Individual differences

n n n n n n

self-motivation Motivational orientation Pain tolerance Athletic identity Coping skills Psychological skills

Demographic

n gender n Age n Prior sport experience

physical

n Use of ergogenic aids n Physical health status n Disordered eating

sITuaTIonal FacTors Cognitive appraisal

Recovery outcomes

behavioural response

Emotional response

sport

Type n Level of competition n Time in season n Playing status n Practice vs game

social

n n n n

environmental

n Rehabilitation environment n Accessibility to rehabilitation

Teammate influence Coach influence Family dynamics sports medicine team influence n sports ethic/philosophy

Figure 2: Integrated model of response to sports injury and rehabilitation [Adapted from Wiese-Bjornstal et al. 1998 (8)]

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sportEX medicine 2014;59(January):10-15

evidence infoRmed pRactice

ATHLETEs WHO bEgIn COMPETIng AFTER A sERIOUs InjURy CAn ExPERIEnCE HEIgHTEnED COMPETITIvE AnxIETy, FOCUs UnnECEssARILy On THE InjURED AREA, AnD sTRUggLE TO REgAIn THEIR TECHnICAL sKILLs AnD AbILITIEs Box 2. sIgns oF poor aDjusTMenT To sporT InjurY [Adapted from Petitpas and Danish, 1995 (9)] 1. Excessive emotional outbursts and mood swings 2. Feelings of inappropriate guilt 3. Withdrawal from significant others 4. Obsession about return to play 5. Dwelling on minor complaints 6. Missing scheduled sessions/meetings 7. Feelings of helplessness.

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stressful and resources to cope with that stress are sought. Common stressors include medical, sportrelated, social, and financial demands.

The Integrated Model of Response to sport Injury by Weise-bjornstal, (8) is one of the most supported of these. This model suggests that both personal (eg. experience of injury) and situational factors (eg. perceptions of social support) relating to being an injured athlete mediate cognitive appraisal. This then subsequently affects emotional responses and behavioural responses influencing recovery outcomes. At the heart of the model (see Fig. 2) is a dynamic core which should be appreciated as a three-dimensional spiral towards full recovery (heading upward in clockwise direction) and away from full recovery (heading downward in counter clockwise direction). Essentially what the research tells us is that an athlete’s psychological response to sports injury has to be seen as being dynamic, highly individualised, and changes in

direction and magnitude over time (box 2)(14).

recoverY FroM sporTs InjurY Complete holistic recovery from sports injury takes place only when the athlete is healed physically and psychologically.

The psychological transition from sport-specific function to return to play is an under-researched one. For example whether an athlete who has had a significant injury ever identifies themselves as being fully recovered, having low injury risk compared to others, and perceive a return to a high level of personal performance is relatively unknown. Anecdotally, athletes may return to play preoccupied with the injury they previously sustained and shy away from important tackles or avoid risky movement patterns. They may see the sustaining of an injury in a more global way and now feel fallible and much more injury prone. It has also been suggested that athletes who begin competing after a serious injury

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can experience heightened competitive anxiety, focus unnecessarily on the injured area, and struggle to regain their technical skills and abilities (15). This has been suggested as a contributing factor in explaining poor post-injury performance and the high rates of recurrent injuries found within sport. Common indications that an athlete may be experiencing re-injury anxieties include expressing heightened negative emotions towards the completion of a rehabilitation programme, malingering to deliberately delay rehabilitation progress or hesitation in trying sport-specific drills and tests of which they are physically capable (16). A recent literature review based on the psychology of athletes returning to sport after serious injury found there were common concerns with re-injury, an inability to perform to pre-injury standards, feelings of isolation, loss of athletic and team-based identity, insufficient social support, increased pressure to return before being ready and self-

Box 3: pracTITIoner TIps To ease TransITIon Back InTo sporT 1. be aware that physical and psychological healing may not coincide within the same time frame 2. Mirror how the player got injured originally in rehab to increase confidence this won’t necessarily happen again 3. In your ‘return to training and play’ criteria acknowledge psychological readiness to return 4. Place the player in a different coloured bib when returning to training and set conditions such as no tackling to other players to ensure this is low risk and increases the athlete’s confidence.

presentational issues (15). This highlights that the experience of returning to sport post-injury is one littered with stressors and raising the awareness of this may well help the practitioner ease the transition back into full play (box 3).

conclusIon As practitioners we are often left frustrated at the lack of commitment to rehabilitation and rate of re-injury when an athlete is deemed ‘fit’. From the evidence it is clear that there are important psychosocial factors relating to sports injury risk, an athlete’s response to sustaining injury, and

THERE ARE MAny qUEsTIOnnAIREs THAT CAn bE UsED As OUTCOME MEAsUREs OF PsyCHOLOgICAL REsPOnsE TO InjURy

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that they are present upon returning to training/play. This highlights the importance of practitioners working using a bio-psychosocial approach (17,18) in preventative strategies and to rehabilitate sports injury to ensure that full holistic recovery takes place.

References 1. brown C. Injuries: the psychology of recovery and rehab. In: Murphy s (ed.) The sport Psych Handbook, pp.215–235. Human kinetics 2005. isBn 0736049045 (£14.10). buy from Amazon http://spxj.nl/1c8xzTr 2. Kolt gs. Doing sport psychology with Mb (ed.) Doing injured athletes. In: Andersen M sport Psychology, pp.223–236. Human s kinetics 2000. isBn 0736000860 k (36.99). buy from Amazon http://spxj. nl/18dD9g4 nl/18dD9 3. Podlog L, Eklund RC. The psychosocial aspects of a return to sport following serious injury: a review of the literature from a self-determination perspective. psychology of sport and exercise 2007;8:535–566 4. Williams jM, Anderson Mb. Psychosocial antecedents of sport injury: review and critique of the stress and injury model.

Journal of applied sport psychology 1998;10:5–25 5. Maddison R, Prapavessis H. A psychological approach to the prediction and prevention of athletic injury. Journal of sport and exercise psychology 2005;27:289–310 6. Ivarsson A, johnson U. Psychological factors as predictors of injuries among senior soccer players: a prospective study.

Journal of sports science and medicine 2010;9:347–352 7. nippert AH, smith AM. Psychologic stress related to injury and impact on sport performance. physical medicine and Rehabilitation clinics of north america 2008;19:399–418 8. Wiese-bjornstal DM, smith AM, shaffer sM, et al. An integrated model of response to sport injury: psychological and sociological dynamics. Journal of applied sport psychology 1998;10:46–69 9. Petitpas A, Danish sj. Caring for the injured athlete. In: Murphy sM (ed) sport Psychology Interventions, pp.255–281.

Human kinetics 1995. isBn 0873226593 sportEX medicine 2014;59(January):10-15

evidence infoRmed pRactice

(£46.73). buy from Amazon http://spxj.nl/1gACelp 10. brewer bW, van Raalte jL, Petitpas Aj. A Patient practitioner interactions in sports injury rehabilitation. In: Pargman D (ed) Psychological bases of sports Injury, 3rd edn., pp.79–94. fitness information technology 2007.

Isbn 978-1885693754 (£47.12). buy from Amazon http://spxj.nl/1dMZa3n 11. Kübler-Ross E. On Death and Dying. macmillan 1969. isBn 978-0415040150 (£21.90). buy from Amazon http://spxj.nl/187nwCq 12. Walker n, Thatcher j, j Lavallee D. Psychological responses to injury in competitive sport: a critical review. Journal of the Royal society for the promotion of Health 2007;127(4):174–180 13. Carson F, Polman RC. ACL injury rehabilitation: a psychological case study of a professional rugby union player.

Journal of clinical sports psychology 2008;2:71–90 14. grindstaff js, Wrisberg CA, Ross jR. Collegiate athletes’ experience of the meaning of sport injury: a phenomenological investigation. perspectives in public health 2010;130(3):127–135 15. Podlog L, Dimmock j, Miller j. A review of return to sport concerns following injury rehabilitation: Practitioner strategies for enhancing recovery outcomes. physical therapy herapy in sport 2011;12:36–42 16. Heil j. Psychology of sport injury. Human kinetics 1993. isBn: 978-0880115643 is (£90.85). buy from Amazon http://spxj.nl/1k58jlr 17. brewer bW, Andersen Mb, van b Raalte jL. Psychological aspects of sport injury rehabilitation: toward a biopsychological approach. In: Mostofsky DI and Zaichkowsky LD (eds.) Medical Aspects of sport and Exercise, pp.41–54. fitness information technology 2006. isBn 188569329X (£31.04). buy from Amazon http://spxj.nl/1eRMnd2 18. Engel gL. The need for a new medical model: a challenge for biomedicine. science 1977;196:129–136.

Fur FurTher resources 1. Foundations in Sport Therapy by A. gledhill, n.

Mackay, D. Forsdyke and K. Randerson. heinemann 2011. IsBn 0435046853 (£23.59). buy from Amazon http://spxj.nl/1dn1w27 2. The Psychology of Sport Injury and Rehabilitatio Rehabilitation, editors M. ArvinenArvinen-barrow and n. Walker. routledge www.sportEX.net

2013. IsBn 978-0415695893 (£22.99). buy from Amazon http://spxj.nl/IDvrM3 3. Psychological Bases of Sport

online

Injuries, editor D. Pargman. Fitness Information Technology 2007. IsBn 978-1885693754 (£47.12). buy from Amazon http://spxj.nl/1bbsUyw

If you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access.

video clip showing Dan carter (new Zealand rugby union) give a press conference about injury and its effects. (http://spxj.nl/1k5dLo9). Courtesy of Youtube user nzheraldtv

Th AuThoR ThE Dale Forsdyke (MSc, MSST, MSMA, FFhEA) is a lecturer in sports injury management at York St John university and a practising sports therapist. he has dual professional body status with the SST and SMA, and has completed MSc qualifications in both sports science, and sports therapy. Dale has previously written sports therapy programmes and has co-authored the book Foundations in Sports Therapy. he is currently undertaking a PhD looking at the experience and meaning of being an injured athlete. For correspondence please email d.forsdyke@yorksj.ac.uk, and follow his Twitter account: @forsdyke_dale.

DISCUSSIONS

n To what extent do you think sports injury is caused by psychological as opposed to physiological factors? n How can you apply the knowledge from this article in your own practice? n What are the challenges to working using a bio-psychosocial approach? n What would you classify as being ‘normal’ psychosocial responses to injury (yellow flags) versus ‘severe’ responses (orange flags)?

continuing education Multiple choice questions This article also has an eLearning test which can be found under the eLearning section of our website.

Tests from April 2013 onwards can be done on most digital devices.

1. Login to our website, click the Online Access button in the main menu bar and the go to the eLearning section (you must be logged in).

2. Click on the quiz you wish to do. successful completion results in a stored certificate under the My Account area of our website. This can be downloaded or printed at any time as evidence of continuing education for many national and international membership associations.

tHis quiz is accessiBle

fRee

witH a suBscRiption tHat includes online access to tHis JouRnal.

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Hamstring injuries in football assessment, diagnosis and prognosis This article provides an update on the current available evidence on the assessment, diagnosis, and prognosis of hamstring injuries in soccer. After a detailed insight into the epidemiology, functional anatomy and injury mechanism for hamstring injuries, a detailed clinical examination – which is supported by clinical evidence, clinical experience and innovative practice – is demonstrated. Finally the recent Munich classification system is presented to improve clarity of communication for diagnostic, therapeutic and prognostic purposes.

BY WaYne Gill BSc, McSP

ePideMioloGY Injury to the hamstring muscle group is frequently reported to be the most common injury in professional football representing 12% of all injuries (1). It has been reported that 83% of hamstring injuries affect the biceps femoris, whereas 10% and 5% affect the semimembranosus and semitendinosus, respectively (2). A 25-player squad can expect five hamstring muscle injuries each season, resulting in 90 days and 15–21 matches missed per club per season (3). It’s been reported that 18 days and 3 matches are missed per hamstring strain, with a 12% re-injury rate (3). Re-injuries can lead to diminished athletic performance and frustration for the player (4). Injuries will also have a negative impact on the morale, performance, and results of the team, which can have huge financial implications for the club (4). Thus, hamstring strain injuries remain one of the most challenging injuries facing sports medicine practitioners.

anatoMY The hamstring muscle group includes the semitendinosus (ST) and semimembranosus (SM) medially and the biceps femoris (BF), short and long heads, laterally. All muscles attach proximally to the ischial tuberosity, except the BF short head, which originates at the linea aspera and lateral supracondylar line of the femur (5). The ST attaches to the medial surface of the superior tibia, SM to the posterior part of the medial condyle of the tibia and the oblique popliteal ligament, while the BF attaches to the fibular head. The BF also has strong fascial connections to the peroneus longus at the fibula linking it to the action of the ankle and foot (6).

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Additionally, the SM has expansions extending to the knee joint capsule and the medial meniscus (Fig. 1; Video 1)(6).

Function The hamstrings are biarticular (2-joint) muscles spanning the hip and knee joint with multiple attachments that allow them to affect function throughout the pelvis and lower extremities. The principle activities of the hamstring group are hip extension and knee flexion. However, the BF short head crosses only the knee joint and is therefore only involved in knee flexion. Additionally, with the knee in flexion the SM and ST can medially rotate the tibia, whereas the BF laterally rotates the tibia. The hamstrings are predominantly made up of type II fast twitch fibres and are innervated by the tibial branch of the sciatica nerve. However, the BF short head is dually innervated by both the tibial and peroneal portion of the sciatic nerve (7). Functionally, the muscle group provides knee support during the early stance phase, propulsion during the mid to late stance phase and they control knee momentum during the swing phase (8). Studies of running biomechanics have found the hamstrings are active for the entire gait with peaks in activation during the terminal swing and early stance phases (9,10). During the terminal swing phase the hamstrings are required to contract eccentrically to decelerate the flexing hip and extending knee in preparation for heel strike (11). Furthermore, using electromyography (EMG) analysis it’s been reported the BF is maximally activated between 15° and 30° of knee flexion, whereas the ST and SM are maximally activated between 90° and 105° of knee flexion (12). This indicates that the BF participates strongly during the terminal swing phase of running. Additionally, during the early stance phase the hamstrings have to absorb considerable force as sportEX medicine 2014;59(January):16-22

evidence informed practice

a result of high ground reaction forces (10,11). Furthermore, the thoracolumbar fascia (TLF) via its extensive muscular attachments functionally connects the hamstrings to the lumbar-pelvic spine and the upper torso (6).

injurY MechaniSM It has been reported that 70% of hamstring injuries in elite football players occur during high speed running and the rest with stretching, sliding, twisting, turning, passing and jumping (13). The presence of high eccentric forces during the stance and swing phases likely contributes to the high rates of hamstring injuries during maximal speed running. The terminal swing phase is considered the most hazardous as the hamstring muscle tendon units are at their longest length

of the gait cycle and are most heavily activated (11,14). This eccentric breaking force is often the point of muscle failure as the lengthening demands placed on the muscle exceed the mechanical limits of the muscle. This is postulated to be due to non-uniform lengthening of sarcomeres attributed to sarcomere length instability. There is some uncertainty as to whether hamstring injuries most typically occur as a result of the accumulation of microscopic muscle damage, or as a result of a single event (11). It seems feasible, however, that both may contribute. For example, the accumulation of microscopic damage as a result of repeated sprints may cause a ‘weak link’ and leave the muscle tissue in a vulnerable state and more susceptible to injury during a single traumatic event, such as kicking a ball (11).

exaMination history Most soccer players with hamstring strain injuries present with a sudden onset of posterior thigh pain resulting from a specific action, most commonly high speed running (3).

Players will often describe the occurrence of an audible pop or tearing sensation. However, a more gradual onset of hamstring pain may be more suggestive of a referred source, or what is commonly termed back-related hamstring pain (15). The lumbar spine especially at the L5/S1 levels, and the

online if you have a current subscription, login at www. sportex.net to view this video or download the mobile apps which are free to subscribers with online access. © Primal Pictures 2013

Video 1: anatomy animation showing hamstrings with surrounding musculature

Figure 1a: Biceps femoris in isolation

Biceps femoris

Semitendinosus Semimembranonosus

© Primal Pictures 2013

Figure 1b: Muscles that make up the hamstrings

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HAMSTRInG InJuRIES REMAIn onE oF THE MoST cHALLEnGInG InJuRIES FAcInG SPoRTS MEDIcInE PRAcTITIonERS

tuberosity, in addition to measuring the total length of the painful region (15). Palpation also serves detect (superficial or larger) tears, perimuscular oedema and any increase in muscle tone (18). The examiner can also palpate the gluteal muscles to determine the presence of any MTPs which may also refer pain into the hamstring region. Additionally, the superior tibia-fibula joint (STFJ) should be assessed in hamstring injuries involving the BF (3).

sacroiliac joints (SIJ) can refer pain to the posterior thigh especially if there has been a history of low back pathology (16). This type of hamstring pain that occurs during training is often due to increased loading of the lumbar spine. Therefore, an investigation into the training history could lead to important information regarding the causes of spine-related hamstring injuries. Additionally, myofascial trigger points (MTPs) from the gluteal muscles and the piriformis muscle may also refer pain into the hamstring region (17).

Palpation

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Palpation of the posterior thigh is useful for identifying the specific muscle and location injured through pain provocation, as well as determining the presence/absence of a palpable defect in the musculotendinous unit (15). The point of maximal pain can be determined and located relative to the ischial

Figure 2: Knee flexion (90°) using hand-held dynamometer (HHD)

Figure 3: Knee flexion (45°) using HHD

Figure 4: Knee flexion (15°) using HHD

Figure 5: Hip extension performed with knee extension

Figure 6: Hip extension performed with knee flexion

sportEX medicine 2014;59(January):16-22

EvidEncE informEd practicE

Flexibility and neural tension The Lasègue test, otherwise known as the straight leg raise (SLR) test, is commonly used to assess hamstring flexibility in soccer players (19). However, it’s suggested the SLR test has a dual function in measuring hamstring muscle length and assessing sciatic nerve mobility (20). Indeed, the SLR causes caudal movement of the sciatic nerve, and this stretching may cause a protective contraction of the hamstrings if there is entrapment of the sciatic nerve in the intervertebral canal due to disc prolapse, degenerative osteophytes, or other structures (21,22). Thus, in pathological states of the lower back, restriction may not be due to hamstring muscle injury, but muscle spasms in these muscles caused by irritation to the sciatic nerve (22). Despite this, the validity of the SLR test in the diagnosis of neural tension remains inconclusive (23). Due to the confusion about the SLR test, Gajdosik and Lusin (24) designed the active knee extension (AKE) test to measure hamstring length by the angle of the knee flexion during AKE while the hip is stabilised at 90° flexion. Thus, the AKE is thought to be more selective than the SLR test at measuring hamstring length alone (24). Furthermore, the intratester reliability has been reported as high (25). The modified sit and reach (mSAR) test has been advocated as a general lumbar spine and hamstring flexibility test rather than a direct hamstring muscle length (19). The slump test is often used to assess adverse neural tension, and involves tensioning the neural system without additional hamstring stretch (26,27). The goal of the test is to differentiate nerve root pain from muscle pain (22). A positive test is defined as one which reproduces the symptoms during simultaneous knee extension and ankle dorsiflexion, and alleviated with cervical extension (27,28).

The pain elicited by the slump test is thought to be due to excessive nerve stretch (intraneural), or reduced neural mobility at the interface with the surrounding muscle tissue (extraneural) (28). Recently, three flexibility tests have been advocated for diagnosing proximal hamstring tendinopathy (PHT), and these include the Puranen–orava (Po) test, the bent-knee stretch (BK) test and the modified bent-knee stretch (MBK) tests. All three clinical tests are practical, easy to perform, and have demonstrated high validity and reliability for diagnosing PHT (29).

Joel Ward striking the ball for Portsmouth FC (Photo credit: Joe Pepler, 2011)

THE MunIcH MuScLE InJuRy cLASSIFIcATIon cAn BE uSED To ASSIST DIAGnoSIS By cLASSIFyInG HAMSTRInG InJuRIES InTo FuncTIonAL oR STRucTuRAL InJuRIES

online

if you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access.

Video: demostration of the hip extension test

Strength Hamstring strength can be evaluated in both the supine and prone positions. With the player in the prone position manual muscle testing (MMT) can be used to assess the isometric knee flexion strength initially at 90° (Fig. 2), then 45° (Fig. 3), and finally 15° (Fig. 4) of knee flexion. Additionally, the use of a hand-held dynamometer (HHD) can provide objective measurements and identification of any strength deficits at different knee flexion angles between the injured and noninjured side (30). With adequate stabilisation the HHD is a valid and reliable method of assessing hamstring strength (31, 32). Also, the concentric and eccentric hamstring strength can be assessed using manual resistance applied by the hands of the clinician. To place more emphasis on the BF it’s suggested the knee should be externally rotated, whereas internal rotation would bias the medial hamstrings (15).

Because the hamstring muscles extend the hip, it’s been www.sportEX.net

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recommended that hip extension strength be assessed with full knee extension and also knee flexion (15). The elevated single leg bridge test is a quick and simple way of assessing hip extension and can be performed with the knee fully extended and also flexed (Figs 5, 6; Video 2). collectively, the aforementioned strength tests will provide the examiner with subjective and objective markers which can be used to monitor the progression and recovery throughout the rehabilitation process.

lumbar spine and pelvis The pelvis provides a dynamic link between the trunk, vertebral column and the lower limbs and has been described as the keystone for both movement and support (33). Therefore, asymmetry or dysfunction within pelvic structures can alter movement patterns resulting in less efficient movement, and alterations in joint forces and muscle function (34). Due to the anatomical and functional relationship with the pelvis the hamstrings may be vulnerable to injury. Excessive anterior tilt of the pelvis due to sacroiliac joint (SIJ) dysfunction will increase the muscle length and tension within the hamstring muscles, thus predisposing them to injury (35,36). The function of the SIJ may be assessed by a number of kinetic tests, including the stork test (also known as the Gillet test) and the forward flexion test (37).

Additionally, the position of the pelvis should be examined to determine the presence of any postural asymmetries which may also indicate a true or apparent leg length discrepancy (38,39). The lying/sitting test is a clinical method frequently used to differentiate between a true and apparent leg length discrepancy (40). The active straight leg raise (ASLR) test has recently been used as a screen of lumbar spine stability to assess the control of lumbar rotational movements in the transverse plane (41). Good control without anterior pelvic tilt is required and excessive anterior pelvic tilt typically accentuates the lumbar lordosis and can be a sign of poor stabilisation of the pelvis by the abdominal muscles (6, 30).

Therefore, a thorough biomechanical evaluation of the lumbar

taBle 1: claSSiFication oF acute MuScle diSorderS and injurieS [Adapted from Mueller-Wohlfart et al., 2013 (18)]

Indirect muscle injury

Functional muscle disorder

Type 1: overexertionrelated disorder

1a: Fatigue induced 1b: Delayed onset of muscle soreness (DoMS)

Type 2: neuromuscular disorder

2a: Spine-related neuromuscular disorder 2b: Muscle-related neuromuscular disorder

Type 3: Partial muscle tear Structural muscle injury Type 4: (Sub) total tear Direct muscle injury

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3a: Minor partial muscle tear 3b: Moderate partial muscle tear Subtotal or complete muscle tear Tendinous avulsion

taBle 2: Mri claSSiFication and Mean recoVerY tiMeS

[Adapted from Ekstrand et al., 2012 (2)] Mri Findings classification Grade 0 no visible pathology Grade I oedema but no architectural distortion Grade II Architectural distortion (partial tear) Grade III Total muscle or tendon rupture

return to training (days) 8 17 22 73

taBle 3: Munich claSSiFication SYSteM and Mean recoVerY tiMeS [Adapted from Ekstrand et al., 2013 (43)] Muscle classification Functional disorders

Structural disorders

Delayed onset of muscle soreness Spine-related neuromuscular muscle disorders Fatigue induced Muscle-related neuromuscular muscle disorders Minor partial muscle tears Moderate partial muscle tears Subtotal/complete muscle injury/tendinous avulsion

return to training (days) 4.5

7.0 7.9 13.8 17.3 35.5

56.3

spine, SIJ, and the pelvis should be included as part of the injury assessment.

diaGnoSiS The diagnosis is based on the clinical history, examination findings, and the use of imaging modalities such as ultrasound and magnetic resonance imaging (MRI). An early post-injury ultrasound between 2 and 48 hours has been advocated as it can provide helpful information about any existing disturbance of the muscle structure, particularly if there is any haematoma (18). However, MRI is considered superior for evaluating injuries to deep portions of the muscles, or when a previous hamstring injury is present, as residual scarring can be misinterpreted on an uS image as an acute injury (42). Furthermore, due to its increased sensitivity in showing subtle oedema, measuring the size (length and cross sectional area) and site of injury including any tendon involvement, MRI is more accurate (42). Thus, an MRI examination within 24–48 hours of the injury event should be performed (2,18).

classification contusion or laceration

currently the most widely used classification for hamstring injuries is an MRI based graduation defining four grades: grade 0, no visible pathology; grade 1, oedema but no sportEX medicine 2014;59(January):16-22

evidence informed practice

architectural distortion; grade 2, partial tear with architectural disruption; and grade 3, total muscle or tendon rupture (2). Around 70% of hamstring injuries seen in professional football are of radiological grade 0 or 1, meaning no signs of fibre disruption on MRI. However, these injuries caused more than 50% of the absence of players in clubs (2). The actual cause of posterior thigh injury where MRI shows no pathology is unclear, but may be due to an alternative diagnosis. Recently the Munich muscle injury classification was introduced as a new terminology and classification system of muscle injuries (18). This clinical tool can be used to assist diagnosis by classifying muscle injuries into functional and structural injuries. Functional disorders are fatigue induced or neurogenic injuries causing muscle dysfunction without microscopic evidence of fibre tear, while structural injuries are tears of muscle fibres (Table 1).

In elite professional football it has been reported that 65% of hamstring injuries are structural injuries and 35% are functional disorders (43).

Prognosis The ability to predict lay-off time is very important for the injured player as well as the coaching staff. Recent studies evaluating the use of MRI have demonstrated that MRI abnormalities can not only confirm the clinical diagnosis, but also provide a reasonable estimate of the rehabilitation period (2,44). Ekstrand et al. (2) assessed the prognostic value of MRI by grading the severity of 516 hamstring injuries in football players (Table 2). Additionally, Ekstrand et al. (43) recently demonstrated the Munich muscle classification can be used by clinicians to prognosticate return to play after a muscle injury in football players (Table 3).

The Munich classification clearly shows a difference in return to play between structural and functional muscle injuries. This seems logical since by definition structural injuries show macroscopic evidence of muscle fibre damage, and functional disorders show no such damage (18). Establishing the type of injury also provides essential prognostic information since a stretching-type of injury has, on the average, 84% longer times (59 vs 32 days) to return than a sprinting-type of injury (43). other measurements with similar prognostic value, that is, prolonging or shortening the time to return, are position of peak pain upon palpation in relation to the ischial tuberosity as well as oedema length upon MRI. The shorter the distance to the ischial tuberosity and the longer the length of the oedema have been associated with longer recovery times (43). Hamstring tears >60mm (6cm) in length or >10% cross sectional area (cSA) have been shown to have a recovery time of at least 3 weeks (45,46). Additionally, more than 1 day of walking with pain has also been associated with a recovery time of at least 3 weeks (46). Injuries involving disruption to tendinous tissue (central or proximal free tendons) have a significantly worse prognosis than injuries which involve only muscle fibres, epimysial fascia, or the musculotendinous junction (44). This may be reflective of the increased remodelling time required of tendinous injuries. Therefore, the length of rehabilitation is proportional to the classification, location, and severity of injury. www.sportEX.net

THE MunIcH cLASSIFIcATIon cAn BE uSED By cLInIcIAnS To PRoGnoSTIcATE A RETuRn To PLAy FoR FooTBALL PLAyERS SuMMarY This article provides the reader with an update on the current available evidence on the assessment, diagnosis, and prognosis of hamstring injuries in football. The diagnosis is based on the clinical history, examination findings, and the use of imaging modalities such as ultrasound and MRI. The Munich classification tool has been introduced to assist diagnosis by classifying muscle injuries into functional and structural injuries and improve clarity of communication for diagnostic, therapeutic and prognostic purposes. references 1. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the uEFA injury study. british journal of sports medicine 2011;45:553–558 2. Ekstrand J, Healy J, et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. british journal of sports medicine 2012;46:112–117 3. Woods c, Hawkins R, et al. The Football Association Medical Research Programme: an audit of injuries in professional football – analysis of hamstring injuries. british journal of sports medicine 2004;38:36–41 4. Liu H, Garrett W, et al. Injury rate, mechanism, and risk factors of hamstring strain injuries in sports. A review of the literature. journal of sport and Health science 2012;1:92–101 5. Ali K, Leland M. Hamstring strains and tears in the athlete. clinics in sports medicine 2012;31:263–272 6. Hoskins W, Pollard H. The management of hamstring injury – part 1: issues in diagnosis. manual therapy 2005;10:96–107 7. Gray H. Gray’s anatomy: the anatomical basis of clinical practice.

Standring S (ed.), Section 9, pp1377. churchill livingston 2008. asin b00a357Que (£254.90) Buy from Amazon http://spxj.nl/1gBucz6 8. Adebe E, Moorman cT, T, Garrett WE. Proximal hamstring avulsion injuries: injury mechanism, diagnosis and disease course. operative techniques in sports medicine 2012;20:2–6 9. yu B, Queen R, et al. Hamstring muscle kinematics and and activation during overground sprinting. journal of biomechanics 2008;14(41):3121–3126 10. chumanov E, Heiderscheit B, Thelen D. Hamstring musculotendon dynamics during stance and swing phase phases of high speed running. medicine & science in sports & exercise 2011;43(3):525–532 11. opar D, Williams M, Shield A. Hamstring strain injuries. Factors that lead to injury and re-injury. sports medicine 2012;43(3):209–226 12. onishi H, yagi R, et al. EMG-angle relationship of the hamstring muscles during maximum knee flexion. journal of electromyography and Kinesiology 2002;12:399–406 13. Ekstrand J, Healy J, et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. british journal of sports medicine 2012;46:112–117 14. Thelen D, chumanov E, et al. Hamstring muscle kinematics during treadmill sprinting. medicine & science in sports & exercise 2005;37(1):108–114 15. Heiderscheit B, Sherry M, et al. Hamstring strain injuries: Recommendations for diagnosis, rehabilitation and injury prevention. journal of orthopaedic & sports physical therapy 2010;40(2):67–81 16. orchard J, Farhart P, Leopold c. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection?

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b british journal of sports medicine 2004;38:502–504 17. Asher S. The concise book of trigger points, 2nd edn, pp148– 159. loftus publishing 2008. isbn 1556437455 (£14.49). Buy from Amazon http://spxj.nl/IckABx 18. Mueller-Wohlfahrt H, Haensel L, et al. Terminology and classification of muscle injuries in sport; The Munich consensus statement. british journal of sports medicine 2013;47:342–350 19. Rolls A, George K. The relationship between hamstring muscle injuries and hamstring muscle length in young elite footballers. physical therapy in sport 2004;5:179–187 20. Dixon J, Keating J. Variability in straight leg raise measurements. physiotherapy 2000;86(7):361–370 21. ylinen J, Kautiainen H, Hakkinen A. comparison of active, manual, and instrumental straight leg raise in measuring hamstring extensibility. Journal of strength and conditioning research 2010;24(4):972–977 22. McHugh M, Johnson c, Morrision R. The role of neural tension in hamstring flexibility. scandinavian journal of medicine & science in sports 2012;22:164–169 23. capra F, Vanti c, et al. Validity of the straight leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. journal of manipulative physiology therapy 2011;34:231–238 24. Gajdosik R, Lusin G. Hamstring muscle tightness: reliability of the active knee extension test. physical therapy 1983;63(7):1085–1090 25. Gajdosik R, Rieck M, et al. comaprison of four clinical tests for assessing hamstring muscle length. journal of orthopaedic sports physical therapy 1993;18(5):614–618 26. Kornberg c, Lew P. The effect of stretching neural structures on grade one hamstring injuries. journal of orthopaedic sports physical therapy 1989;10:481–487 27. Miller K. The slump test: clinical applications and interpretations. chiropractic technique 1999;11(4):157–163 28. Turl S, George K. Adverse neural tension: a factor in repetitive hamstring strain? journal of orthopaedic sports physical therapy 1998;27:16–21 29. cacchio A, Borra F, et al. Reliability and Validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. british journal of sports medicine 2012;46:883–887 30. Mendiguchia J, Brughelli M. A return to sport algorithm for acute hamstring injuries. physical therapy in sport 2011;12:2–14 31. Kelln B, McKeon P, et al. Hand-held dynamometry: reliability of lower extremity muscle testing in healthy, active, young adults. journal of sport rehabilitation 2008;17:160–170 32. Trudelle-JacksonE, Jackson A, et al. Interdevice reliability and validity assessment of the nicholas hand held dynamometer. journal of orthopaedic rthopaedic & sports physical therapy 1994;20(6):302–306 33. Lee D. The pelvic girdle: an approach to the examination and treatment of the lumbopelvic-hip region, 3rd edn, pp41–61. churchill livingston 2004. isbn 0443073732 (£38.75). c Buy from Amazon http://spxj.nl/1auEqp4 34. Sahrmann S. Diagnosis and treatment of movement impairment syndromes, pp74–84. mosby 2002. isbn 0801672058 (£47.00 print, £35.25 kindle). Buy from Amazon http://spxj.nl/1gBw6Jn 35. cibulka M, Rose S, et al. Hamstring muscle strain treated by mobilizing the sacroiliac joint. physical therapy 1986;66(8):1220–1223 36. Hennessy L, Watson A. Flexibility and posture assessment in relation to hamstring injury. british journal of sports medicine 1993;27(4):243–246 37. Wurff P, Hagmeijer R, Meyne W. clinical tests of the sacroiliac joint – part 1: reliability. manual therapy 2000;5(1):30–36 38. Herrington L. Assessment of the degree of pelvic tilt within a normal asymptomatic population. manual therapy 2011;16:646–648 39. Gurney B. Leg length discrepancy. gait posture 2002;15:195–206 40. Bemis T, Daniel M. Validation of the long sitting test on subjects with iliosacral dysfunction. journal of orthopaedic & sports physical therapy 1987;8(7):336–345 41. Liebenson c, Karpoowicz A, et al. the american academy of physical medicine and rehabilitation 2009;1:530–535 22

42. connell D, Schneider-Kolsky M, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. american journal of roentgenology diagnostic imaging and related sciences 2004;183(4):975–984 43. Ekstrand J, Askling c, et al. Return to play after thigh muscle injury in elite football players: implementation and validation of the Munich muscle injury classification. british journal of sports medicine 2013;47:769–774 44. comin J, Malliaras P, et al. Return to competitive Play after hamstring injuries involving disruption of the central tendon. the american journal of sports medicine 2013;41(1):111–115 45. Gibbs n, cross T, et al. The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring muscle strains within the same season in Australian Rules football players. journal of science and medicine in sport 2004;7(2):248–258 46. Warren P, Gabbe B, et al. clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. british journal of sports medicine 2010;44:415–419.

ThE AuThor Th Wayne spent 10 years as a professional footballer playing for Blackburn rovers, Blackpool, Tranmere rovers and oldham Athletic before retiring in 2004 due to injury. In 1999 he completed an hNC in sports science and in 2008 he graduated from the university of Salford with a first class honours degree in physiotherapy. Following his graduation he worked at Portsmouth FC for 4 years which included being involved in the FA Cup final in 2010. In 2012 he joined Fulham FC and is currently studying for an MSc in Sports Physiotherapy at Bath university.

DISCUSSIONS

n Describe the function of the hamstrings during the gait cycle. n What is the most common injury mechanism for hamstring injuries? n Which clinical tests would you use to assess hamstring muscle flexibility and neural tension? n Describe the different types of functional and structural disorders associated with the Munich classification.

continuing education Multiple choice questions This article also has an eLearning test which can be found under the eLearning section of our website.

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sportEX medicine 2014;59(January):16-22

liTeraTure review

Taping To TreaT paTellofemoral pain does the science support the hype?

Patellofemoral pain is widely considered to be a condition that is multifactorial in nature and that requires a multimodal approach to its successful management. Taping is commonly used as one treatment element and there is good evidence to support its ability to modify pain and help to restore function. This article aims to provide a critical assessment of the available evidence and to help guide clinicians on the most appropriate taping intervention for individuals with PFP. Gaps in the evidence are highlighted, but potential mechanisms are discussed to ensure clinical utility.

Note from sportEX: Traditionally we publish all tape-related articles in sportEX dynamics, however, we feel because of the current popularity of this topic and its relevance for both sportEX medicine and sportEX dynamics readers, we’ve taken the decision to publish the article in both journals (the first time we’ve done this since Jan 2012). So for people with a double subscription, you’re not going mad if you think you’ve read it before, and to compensate for the double up, we’ve published 8 additional pages of clinical content in each journal (meaning an additional 16 pages for dual-subscribers).

BY SimoN Lack mSc, mcSP

aN EXPLoratioN of thE LitEraturE SurrouNdiNg taPiNg iNtErvENtioNS with ParticuLar rEfErENcE to PatELLofEmoraL PaiN Patellofemoral pain (PFP) is one of the most common musculoskeletal complaints being presented to orthopaedic, general practice (1) and sports medicine clinics (2).

Symptoms are commonly aggravated by activities of daily living, including stair ambulation, prolonged sitting

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and squatting. Although PFP is evident within a wide range of individuals, it is particularly prevalent in younger persons who are physically active (3).

There is a lack of consensus on the exact source of pain, however, patella maltracking resulting in altered loading patterns of the patellofemoral joint (PFJ) is thought to be associated with PFP (3). Proximal, distal and local factors have all been identified as potential contributors to this altered loading. The extent to which each factor relates to the symptoms felt is suspected to vary between individuals.

As a result, numerous conservative interventions such as orthoses, taping

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(a)

(b)

(c)

Figure 1: A demonstration of the components of tailored taping to correct lateral patellar tilt (a), lateral patellar glide (b), lateral patellar spin (c), and to offload Hoffa’s fat pad (d–f).

and exercise are commonly used in rehabilitation. It is, therefore, unsurprising that a multimodal treatment approach has been shown, through systematic review, to represent the ‘gold standard’ approach to managing PFP (4). In order to tailor and improve efficacy of this multimodal approach, the value, mechanisms behind efficacy and the most effective method of application for each multimodal component need to be understood.

Patellar taping forms a core component of the current evidencebased multimodal management programme for PFP. A large variety of taping techniques are subscribed to clinically, with the tailored McConnell taping technique being one of the most widely used (5). Adhesive, rigid tape is applied to the patella in an attempt to

modify lateral glide, tilt or rotation with the primary goal to immediately reduce pain by at least 50% during relevant functional tasks (Fig. 1)(5). Additional taping techniques identified within the literature include untailored medially directed taping (6), inferiorly directed taping and kinesio taping aimed at enhancing vastii muscle activation and synergy (Fig. 2)(7).

Changes to lower limb biomechanics resulting from taping techniques directed proximal and distal to the knee have been investigated, however, the available evidence is limited both in quantity and quality.

With a growing body of evidence reporting positive outcomes following exercise-based hip and foot directed interventions (4), further studies investigating the effect of taping application to these areas are clearly warranted.

This review of the literature aims to bring together the current evidence supporting local patella taping to modify pain, muscle activity and kinematics. In addition the proximal and distal effects of taping will be discussed to provoke discussion about its use clinically, and provide the basis upon which further research could be performed.

taPiNg iNtErvENtioNS dirEctEd at thE kNEE changes in pain Figure 2: Tailored kinesio taping for an individual with patellofemoral pain, including a VMO : VL and lateral fascial offload tape

24

The original taping techniques described

by McConnell (8) were designed with the primary objective of modifying pain sufficiently to enable effective exercise intervention to be performed. The

rationale for which has been supported more recently, as pain acts as a potent inhibitor of normal muscle activity around the anterior knee (9). A current systematic review entitled Taping for patellofemoral pain: A systematic review and meta-analysis to evaluate effectiveness and mechanisms (in press, BJSM) performed by our group at Queen Mary University, concluded that moderate evidence indicates tailored taping provides immediate pain relief of large effect during functional tasks. Additionally, moderate evidence indicates untailored medially directed taping results in immediate pain relief of small effect during functional tasks. Very limited evidence from one low quality study indicates kinesio taping has no effect on pain.

Due to the heterogeneity of taping interventions, data pooling was inappropriate beyond the immediate term. However, one high quality study did report greater pain reduction with McConnell taping in addition to exercise at weeks 2, 3 and 4 of intervention (10). These findings were not supported by an earlier study that reported no improvement following taping intervention plus exercise and education, or taping and education compared with education alone at 3 and 12 months (11). Furthermore, adding kinesio taping to exercise intervention did not demonstrate improvements in pain at 3 or 6 weeks (7).

Further studies, not included in the systematic review mentioned above, have since been published. Osorio et al. (12) compared the immediate sportEX medicine 2014;59(January):23-27

liTeraTure review

(d)

(e)

(f)

A lArGE VArIETy OF TAPInG TECHnIQUES ArE SUBSCrIBED TO ClInICAlly, WITH THE TAIlOrED MCCOnnEll TAPInG TECHnIQUE BEInG OnE OF THE MOST WIDEly USED effects of kinesio and McConnell taping, and when making comparisons between the two techniques reported no significant differences, however significant differences in strength, endurance and pain responses were evident in both groups. However, when comparing kinesio taping with placebo taping, Aytar et al. (13) reported no significant difference in pain between groups. Variability in technique when applying kinesio taping and differences in the functional tasks assessed may well explain this variance in the results obtained.

changes in muscle activity Alteration in vastus medialis oblique (VMO) activation in the presence of PFP has been acknowledged as a potential mechanism through which symptoms are maintained in some individuals (14).

Furthermore, it is believed that altered activation patterns, expressed as an activation ratio of VMO relative to vastus lateralis (Vl), have the capacity to alter the loading patterns within the PFJ. Interventions, such as taping, have therefore been investigated to assess their capacity to elicit change in these activation parameters.

Within our group’s systematic review presented earlier, the results indicated that moderate evidence from within three high quality (and one low quality) studies suggested that VMO onset timing was significantly www.sportEX.net

earlier following a tailored patella taping intervention. Furthermore, limited evidence indicated untailored medially directed taping resulted in a significantly lower VMO : Vl ratio during stair stepping tasks. However, no change in VMO amplitude was observed in either tailored or untailored interventions.

Kinesio taping, purported to have the capacity to alter muscle activation, has been investigated in individuals with and without PFP symptoms. In both groups no changes that are perceived to be advantageous to restoration of normal VMO muscle activity have been reported. Within pain populations, lee et al. (15) reported a reduction in VMO amplitude, and within pain-free populations, lins et al. (16) reported no changes in Vl amplitude following kinesio taping. Despite this lack of conclusive evidence for kinesio taping, the capacity for this style of taping to demonstrate any change in muscle amplitude suggests that potential benefit could be derived. Further work investigating the application technique with regards to specific muscle amplitude measure may reveal rewarding results.

changes in kinematics Kinematic variances, both associated with and leading to PFP, have been well documented within both retrospective and prospective studies (17–19). The effects of taping on these variances

about the knee, however, have been less well reported. Evidence from one high quality study indicates greater knee flexion angles and knee extensor moments during stair ascent and descent under the taped condition (20).

With a 92.6% reduction in pain reported in the same study when individuals were taped, it is made very clear how effective pain modification can be at facilitating a change in movement patterns.

taPiNg iNtErvENtioNS dirEctEd at thE hiP With rotation, and in particular femoral internal rotation, having been highlighted as a significant indicator of PFP development among runners (19), and significantly increased in individuals with PFP during functional tasks (21), an investigation of the effects of taping at the hip is clearly warranted. Furthermore, with current literature reporting that tape applied to the knee has the capacity to alter movement patterns (as described above), the obvious progression is to test if this modality has the capacity to alter movement patterns at the hip.

Conversely, unless the hip tape is able to immediately modify pain, it is possible that alterations in lower limb movement patterns will not be modified as effectively. Kinesio taping directed at the gluteus maximus has been described within the literature to increase muscle 25

power (22). With gluteus maximus as well as gluteus medius activity having been shown to be altered in individuals with PFP (23) this may represent one potential mechanism through which its application may be effective within this population. The literature surrounding tape application to the hip is, however, sparse at best in both pain and painfree populations.

taPiNg iNtErvENtioNS dirEctEd at thE foot Influencing foot position has been of interest in those examining the PFJ because of theoretical paradigms first described in 1987 by Tiberio (24) and particularly since the addition of work

by Powers (25). Tiberio described a link between prolonged pronation, internal tibial rotation and subsequent increased internal femoral rotation to allow for knee extension to occur during the stance phase of gait (24), and Powers demonstrated how influential femoral rotation could be on the loads experienced at the retropatella (25).

To my knowledge no foot taping has been done on individuals with PFP; however, Kelly et al. (26) have published an elegant study looking at the effects of low Dye taping on gluteal, VMO and Vl muscle activity and plantar pressure during running. They reported, however, that application of augmented low Dye taping resulted in a significant delay of electromyographic activity onset for all three muscles when compared with control tape and no tape conditions.

With onset of the glutei reported to be delayed in individuals with PFP (23), an intervention that results in further delay is unlikely to be beneficial. Unfortunately, there was no attempt in this study to differentiate between foot types, which may well influence the findings.

Application of this taping approach in conjunction to a measure of foot posture may well provide interesting results in PFP populations.

coNcLuSioNS There is clearly good evidence to support the use of taping interventions in the management of PFP. In particular, clinicians should include a tailored taping approach likely to positively influence pain (large effect), VMO timing and functional capacity during 26

rehabilitative exercise. Additionally, patellar taping appears to be an effective adjunct to exercise over a 4-week period, however, longer term follow-up to evaluate efficacy is required. The evidence surrounding the use of kinesio taping is largely absent when managing PFP, and where it is present the evidence is low in quality.

Following the high profile of kinesio taping during the Olympics, the rush to ensure good quality research is out there to support its evidence-based use has clearly started and is desperately needed.

References 1. Van Middelkoop M, Van linschoten r, et al.

Knee complaints seen in general practice: active sport participants versus nonsport participants. BmC musculoskeletal Disorders 2008;9:36 2. Taunton JE, ryan MB, et al. A retrospective case-control analysis of 2002 running injuries. British Journal of Sports medicine 2002;36:95–101 3. Powers CM, Bolgla lA, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International research retreat. Journal of orthopaedic & Sports physical Therapy 2012;42:a1–54 4. Collins nJ, Bisset lM, et al. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports medicine 2012;42:31–49 5. Cowan SM, Bennell Kl, Hodges PW. Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome. Clinical Journal of Sport medicine 2002;12:339– 347 6. Keet JH, Gray J, et al. The effect of medial patellar taping on pain, strength and neuromuscular recruitment in subjects with and without patellofemoral pain. physiotherapy 2007;93:45–52 7. Akbas E, Atay AO, yuksel I. The effects of additional kinesio taping over exercise in the treatment of patellofemoral pain syndrome. acta orthopaedica et Traumatologica Turcica 2011;45:335–341 8. McConnell J. The management of chondromalacia patellae: a long term solution. australian Journal of physiotherapy 1986;32:215–223 9. Bennell K, Hodges P, et al. The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad. Journal of orthopaedic research 2004;22:116–121 10. Whittingham M, Palmer S, MacMillan F. Effects of taping on pain and function in patellofemoral pain syndrome: a randomized controlled trial. Journal of orthopaedic & Sports physical Therapy 2004;34:504– 510

11. Clark DI, Downing n, et al. Physiotherapy for anterior knee pain: a randomised controlled trial. annals of the rheumatic Diseases 2000;59:700–704 12. Osorio JA, Vairo Gl, et al. The effects of two therapeutic patellofemoral taping techniques on strength, endurance, and pain responses. physical Therapy in Sport 2013;14:199–206 13. Aytar A, Ozunlu n, et al. Initial effects of kinesio® taping in patients with patellofemoral pain syndrome: A randomized, double-blind study. isokinetics and exercise Science 2011;19:135–142 14. Chester r, Smith TO, et al. The relative timing of VMO and Vl in the aetiology of anterior knee pain: a systematic review and meta-analysis. BmC musculoskeletal Disorders 2008;9:64 15. lee Cr, lee Dy, et al. The effects of kinesio taping on VMO and Vl EMG activities during stair ascent and descent by persons with patellofemoral pain: a preliminary study.

Journal of physical Therapy Science 2012;24 153–156 16. lins CA, neto Fl, et al. Kinesio taping® does not alter neuromuscular performance of femoral quadriceps or lower limb function in healthy subjects: randomized, blind, controlled, clinical trial. manual Therapy 2013;18:41–45 17. lankhorst nE, Bierma-Zeinstra SM, Van Middelkoop M. risk factors for patellofemoral pain syndrome: a systematic review. Journal of orthopaedic & Sports physical Therapy 2012;42:81–94 18. lankhorst nE, Bierma-Zeinstra SM, Van Middelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. British Journal of Sports medicine 2013;47:193–206 19. noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in patellofemoral pain. medicine & Science in Sports & exercise 2013;45:1120–1124 20. Salsich GB, Brechter JH, et al. The effects of patellar taping on knee kinetics, kinematics, and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral pain. Journal of orthopaedic & Sports physical Therapy 2002;32:3–10 21. Aminaka n, Pietrosimone BG, et al.

Patellofemoral pain syndrome alters neuromuscular control and kinetics during stair ambulation. Journal of electromyography and Kinesiology 2011;21:645–651 22. Mostert-Wentzel K, Swart JJ, et al.

Effect of kinesio taping on explosive muscle power of gluteus maximus of male athletes.

South african Journal of Sports medicine 2012;24:75–80 23. Barton CJ, lack S, et al. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British Journal of Sports medicine 2013;47:207–214 24. Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. Journal of orthopaedic & Sports physical Therapy sportEX medicine 2014;59(January):23-27

Literature review

1987;9:160–165 25. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective.

Journal of orthopaedic & Sports physical Therapy 2003;33:639–646

26. Kelly lA, racinais S, et al. Augmented low dye taping changes muscle activation patterns and plantar pressure during treadmill running. Journal of orthopaedic & Sports physical Therapy 2010;40:648–655.

ThE AuThoR Th Simon Lack is a PhD student at Queen Mary university London (QMuL), studying the interaction of hip and foot biomechanics (QM in the presentation and management of patellofemoral pain. he graduated from Brunel university in 2005 with a degree in Physiotherapy, and went on to study an MSc in Sports and Exercise Medicine at QMuL in 2010. Simon works as a physiotherapist in two London-based private clinics, having previously worked in New Zealand with professional golfers, local rugby and football teams.

DISCUSSIONS

n What do you consider to be sub-groups of PFP patients, and how do you tailor your taping intervention to address this? n Which kinesio taping techniques do you use, and what do you think is the mechanism of effect? n Modification of pain appears critical to taping success; through which mechanisms do you think taping achieves this effect?

if you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access.

online

Youtube videos

video 1: Showing kinesio taping for PfP http://spxj.nl/1etkneQ

video 2: Showing tailored mcconnell taping for PfP http://spxj.nl/IsgAVh

Functional Movement based Assessment Dates 2014 London – 25/26th January Crawley hospital – 15/16th March Manchester Met Uni – 12/13th April Exeter, Devon – 17/18th May London – 14/15th June ALL DATES £300 This course will bring cohesion and process to the tasks of functional and dynamic assessment. The majority of patients need to have an element of functionality in their assessment, treatment and rehabilitation process. Learn to bridge the gap between the treatment table and back to playing sport, doing the gardening or just enjoying pain free movement. This can be the missing link to treatment success!

How can you assess movement lying down?

What will you get from this course? ● Enhanced ability to assess using movement instead of guessing from clinical tests ● Utilise movement variables to find and build on pain free movements ● Implement a local (joint) and global (movement pattern) approach to assessment, treatment and training ● Understand modern pain science and its relationship with movement

● Start to use a patient centered approach rather than a protocol based approach ● See the importance of the brain, motor skills, cortical representations & neuroplasticity in pain and movement ● New assessment and treatment options for the ankle, hips and spine with ready to use skills on Monday morning

CONTACT info@cor-kinetic for more details www.cor-kinetic.com

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27

ManageMent of acute patella dislocation A cAse study

BY Sam DawSon BSc, mScP

The InjurY mechanism of injury this case study presents a 16-yearold competitive youth team male footballer who plays as a winger. during a competitive match while running the player tried to dummy in front of an opponent. the player’s leg went into a dynamic valgus position and simultaneously the player tried to pivot in the opposite direction. He immediately felt pain and collapsed. the player was removed from the field of play. subjectively the player reported feeling a ‘pop’ as his knee gave way and felt as if something came out of place and then popped back when he straightened his knee on the floor. Objectively a haemarthrosis was present and the player was able to flex the knee minimally, limited by pain. tenderness was felt medial to the patella and a positive apprehension test was present. the working diagnosis was lateral patella dislocation. due to the mechanism of injury, the anterior cruciate ligament (AcL) was checked but was stable in a Lachman test. the player was booked into trauma clinic at a local hospital so that an X-ray could be performed to rule out osteochondral

cONsIdeR PAteLLOFeMORAL jOINt FORces At ALL stAges OF ReHAbILItAtION 28

this article describes a case study of the diagnosis, assessment and rehabilitation of a youth team footballer who sustained an acute patella dislocation. the study includes all the information needed to effectively rehabilitate players including the mechanism of injury, risk factors, a needs analysis for the sport, problems identified and evidence-based management.

A successful, logical and evidence-based rehabilitation programme is presented, and objective measurement with an evidence base is detailed throughout. this case study was marked as one of the best in class as part of salford university’s Msc sports rehabilitation programme. fracture and loose bodies. the orthopaedic consultant agreed that the AcL was stable and a lateral patella dislocation had occurred. In line with current hospital protocol the player was braced in extension for 3 weeks.

Forces and loads involved conventionally during patella dislocation, the player has their knee in slight flexion with dynamic valgus alignment resulting in a high level eccentric quadriceps contraction which negates the stabilising effect of the vastus medialis obliquus (VMO) (1). the patella stability at this stage depends on individual patellofemoral morphology and the static medial stabilisers. the medial patellofemoral ligament (MPFL) contributes 50% of the static patella stability (2). However, the fibres of VMO

mesh with the fibres MPFL dynamising the MPFL in the first 20–30° of flexion helping maintain the patella in the trochlea (2). considering this, and that the risk of lateral patella dislocation is at its greatest in the first 20–30°, it is likely that the contribution of the MPFL is over the reported 50% static stability (2). As the lateral force produced was higher than 208N, which is the reported tensile load of the MPFL (3), the patella did not engage the trochlea.

With continued knee flexion the patella dislocated causing a tear to the MPFL, potential damage to the VMO and chondral surfaces of the trochlea and patella (1).

Injury risk factors Reported risk factors for first-time patella dislocation include increased sportEX medicine 2014;59(January):28-35

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tibial tubercle to trochlea groove measurement, abnormal patella morphology, increased Q angle with lateral tibial tuberosity, VMO muscle insufficiency, generalised ligament laxity, genu valgum, external tibial torsion, subtalar joint pronation and increased femoral anteversion (4,5).

Of these risk factors the player had

an increased Q angle and patella alta. the injury occurred at 70 minutes into the game and at the time of injury the player was faced with an opponent. both fatigue (6) and inclusion of an opponent (7) have been shown to significantly increase knee valgus loading. Potentially a mix between biomechanical predisposition and

environmental factors during the game may have influenced the occurrence of the injury.

Problems following Injury the initial crucial problems facing the player were pain and effusion. As pain and joint effusion cause altered sensory stimulus and motor responses,

TaBle 1: manaGemenT Plan Problem

action

Timed goal

measurement

Pain

1. Adequate analgesia 2. Ice 3. teNs machine

1. No day-to-day pain 3/52 2. No pain during single leg loading exercises 6/52

n Player subjective reporting (visual analogue scale)

Knee joint effusion

1. compression bandage 2. Isometric muscles setting 3. Progressive loading programme

1. Minimal activity-related effusion 3/52 2. No activity-related effusion 6/52

n Player subjective reporting n joint circumferential measurement

reduced range of movement

1. Range of movement exercises 2. exercise bike

1. Full extension 1/52 2. 90° flexion 4/52 3. Full AROM 6/52

n goniometry twice weekly

reduced confidence loading on injured limb

1. structured exercise programme with gradual increase in loading 2. Load acceptance exercises

1. symmetrical ‘normal’ gait 4/52 2. even loading on bilateral mini squat 4/52 3. control jump/hop landing with good alignment 12/52

n subjective reporting n Functional performance during exercises n gait pattern

Poor dynamic 1. Progressive proprioceptive exercises balance and 2. graded exercise programme stability 3. Load acceptance exercises

1. even control of bilateral mini squat 4/52 2. good dynamic alignment single leg squat 8/52 3. sebt at pre-injury level 12/52 4. Hop test at 95% of uninjured leg 12/52

n QAsLs n sebt n Hop test: single hop, triple hop, cross over hop

Quadriceps strength

1. Progressive quadriceps loading exercises within the consideration of patellofemoral joint forces

1. static quadriceps contraction ×15 reps 1/52 2. straight leg raise ×10 reps no lag 3/52 3. single leg squat with dynamic alignment (0–1 QAsLs) 8/52 4. Hop tests with good alignment 95% of uninjured leg 12/52

n Manual resistance testing n Observation of exercise performance n QAsLs n Hop test: single hop, triple hop, cross over hop

Gluteal strength

Progressive gluteal loading exercises within the consideration of patellofemoral joint forces

1. Active hip abduction supine ×15 reps 1/52 2. side lying hip abduction ×15reps 3/52 3. single leg squat with dynamic alignment (0–1 QAsLs) 8/52 4. Hop tests with good alignment 95% of uninjured leg 12/52

n n n n

risk of redislocation

1. Optimal loading at appropriate time phases 2. Improve lower limb dynamic control 3. education of player of reoccurrence rates.

1. No feeling of instability throughout rehabilitation 2. Negative patella apprehension test 12/52.

n Palpation n Patella apprehension test n subjective reporting.

Manual resistance testing Observation of exercise performance QAsLs Hop test: single hop, triple hop, cross over hop

AROM, active range of movement; QASLS, Qualitative Analysis of Single Leg Squat; SEBT, Star Excursion Balance Test. www.sportEX.net

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early management is required to minimise these detrimental effects.

As the player had been immobilised in extension for 3 weeks he had a reduced range of movement, which would need to be fully restored before progressive loading and returning to sport-specific training. Injury often results in reduced confidence when loading through the injured limb. graded limb loading at the appropriate time should facilitate confidence. Identification of modifiable factors to reduce risk of subsequent dislocation was required. during injury the player demonstrated suboptimal dynamic stability and control. due to muscle atrophy caused by pain and effusion and reduced dynamic control, a reduction in quadriceps and gluteal strength was also identified as a problem.

Football needs analysis during a 90-minute football match distances covered are usually between 9,845 and 11,527m (8). the distance covered is split between jogging (37%), walking (25%), submaximal cruising (20%), sprinting (11%) and moving backwards (7%) (9). sprinting is short in duration (2–4 seconds), short in distance (10–15m) but high in repetition (every 90 seconds) (8). Players turn approximately 50 times during a game each of which produce high velocity movement, requiring forceful muscle contractions and good dynamic control to prevent injury (10).

rehabilitation needs analysis Rehabilitation needed to encompass graded lower limb strengthening with a focus on improving dynamic control to reduce risk of further dislocation and other associated injuries to the knee (11–13). graded exercises targeting gluteus maximus, gluteus medius and quadriceps to improve dynamic alignment (14), patella control and proprioception will be used throughout rehabilitation. In particular, exercises enhancing VMO function due to its role in controlling patella tilt and subluxation are desirable.

However, research suggests that it is not possible to preferentially activate VMO (15), therefore general quadriceps exercises will be used. In the return-tosport phase, rehabilitation exercises will 30

be designed to mimic the high loads and the rapid changes of direction encountered. drills will be performed at multiple speeds to match the multitude of different paces experienced during a game. Introduction of fatigue, opposition and random changes of direction while maintaining good dynamic control are also essential before a return to sport.

manaGemenT Plan: juSTIFIcaTIon anD crITIcal aPPraISal An injury management programme was drawn up as shown in table 1.

Initial management Optimal conservative management following first-time acute patella dislocation is yet to be established.

Maenpaa and Lehto (16) recommended a short period of immobilisation as it appeared to result in fewer dislocations; however, it was also recommended to limit this period to 3 weeks to minimise muscle atrophy and range of movement restrictions. A subsequent systematic review suggests that the quality and size of evidence available cannot justify immobilisation following lateral patella dislocation (17). Potentially the period of immobilisation could have been significantly reduced.

Recent reviews in general soft tissue injury suggest that a period of 2–5 days immobilisation is optimal (18).

Immobilisation during this inflammatory phase would allow the injured area to receive uninterrupted fibroblast invasion leading to optimal cell proliferation and collagen fibre production. during this period a tubigrip with additional compression around the patella could be used to control joint effusion, offer joint support and aid player comfort.

In the proliferation phase of healing (day 3–20) the newly formed scar can tolerate minimal stresses (19). during this phase strengthening exercises which minimise patellofemoral forces and range of movement within the limits of pain could be used.

From day 21 to 60 the formed scar tissue responds to graded stress to remodel (19). Progressive exercises with increasing patellofemoral joint forces would then ensue during this phase. However, good randomised controlled trails are needed to optimise

management following acute patella dislocation.

Muscle atrophy and arthrogenic muscle inhibition (AMI) are seen as the two key reasons for reduction in quadriceps strength after knee injury (20). AMI which presents as voluntary activation failure appears to result from reflex activity which delivers altered sensory information to the injured knee joint leading to poor motor recruitment of the muscles surrounding the joint (20). combating AMI can be achieved by modifying the main inhibitory processes causing it, ie. impacting the motor drive to the muscles or changing the sensory feedback mechanism that is reporting that something is wrong with the knee.

In the context of AMI abnormal sensory input is caused by joint effusion and by the loss of normal sensory feedback from lost mechanoreceptors following ligament injury. Altering the sensory input was achieved through minimising pain, managing the effusion and modification of pre-synaptic inhibition. these are discussed in more detail below.

management of pain Pain following acute patella dislocation comes from the rupture of the MPFL and medial retinaculum and from increased articular pressure from the swelling. In the early stages pain was managed with regular paracetamol (500mg), transcutaneous electrical nerve stimulation (teNs) machine and ice. teNs has been shown to reduce AMI by decreasing pre-synaptic inhibition (21). the teNs machine was used in the initial stages while the player was exercising to maximise its effects (22). In the immediate post-injury phase ice was used to reduce metabolism reducing the degree of tissue damage and secondary hypoxic injury (23). conversely, in the acute rehabilitation stage ice was primarily used to improve pain management to develop exercise tolerance (23). Ice was applied for periods of 10–15 minutes regularly.

Multiple studies have shown after 5–15 minutes of cooling, temperature of the skin is reduced to 13°c which is currently considered the threshold to producing localised analgesia (18).

Ice was applied medially in order to sportEX medicine 2014;59(January):28-35

case study

impact on the infrapatellar branch of the saphenous nerve reducing nerve conduction across the knee.

Measurement tool the visual analogue scale (VAs) was used to identify subjective pain level at the beginning of each session and prior to any activity or exercise to set a baseline score. All activities were performed within a tolerable level of pain. the player was also asked to score their pain at the end of the day and on initial weight-bearing in the morning. the VAs has been shown to be a reliable and valid tool in measuring acute pain (24).

management of swelling Patella dislocation is the second most common cause of haemarthrosis around the knee (25). creating artificial knee joint effusion by infusing fluid has demonstrated negative effects on quadriceps electromyography activity, force output and Hoffman reflex amplitude (26). Adequate control of joint effusion is therefore needed to minimise these detrimental effects and restore normal knee joint function. swelling is an important component of the inflammatory phase of healing, however this needs to be controlled for optimal healing. Anti-inflammatories were not used in the first 72 hours to allow the inflammatory phase of healing to occur. From a physiotherapy perspective compression, elevation and isometric muscle setting were used initially to help manage the swelling. In addition to this the orthopaedic surgeon aspirated the joint at initial appointment with the aim of positive diagnostic and therapeutic effects (5). compression in the form of a double tubigrip with a foam insert which compressed around the patella was used to apply external pressure over the injured area to reduce bleeding and to reduce the build up of oedema in the interstitial space. the player performed regular limb elevation in supine rather than sitting to reduce pooling around the hip. compression and elevation were not used in conjunction with each other (18).

Measurement tool joint circumference measurement around the patella was used and the player was shown how to perform www.sportEX.net

TaBle 2: PaTelloFemoral joInT STreSS DurInG common acTIvITIeS activity

Patellofemoral joint stress

reference

stair climbing

3.3 × body weight

Reilly and Martens, 1972 (28)

step down

20% greater force during step down than step up

chinkulprasert, Vachalathiti and Powers, 2011 (29)

Walking

0.5 × body weight

Reilly and Martens, 1972 (28)

cycling

1.3 × body weight

ericson and Nisell, 1987 (30)

jogging

7.0 × body weight

Nisell and ericson, 1992 (31)

squatting

7.0 × body weight

dahlkvist, Mayo and seedhom, 1982 (32)

this at home. the circumference was recorded twice daily by the player, once during the first hour of the day and once in the evening. this was also performed when the player attended physiotherapy pre- and post-rehab sessions. changes were documented which guided the rehabilitation process.

If significant increases in swelling (>1cm) were noticed then reduction in loading occurred (27).

GraDeD rehaBIlITaTIon ProGramme rehabilitation considerations Patellofemoral loading and soft tissue healing times were important throughout rehabilitation. ensuring exercises did not place excessive force through the patellofemoral joint for the stage of healing was crucial. table 2 was used to guide activities during rehabilitation.

All exercises were performed in a comfortable range and the player was monitored closely throughout rehabilitation.

Immobilisation phase (0–3 weeks) the aims of this phase were to control effusion and pain and to overcome AMI and minimise atrophy. control of effusion, pain and AMI have been discussed in previous sections.

Minimising atrophy was achieved by selecting exercises which activated the quadriceps and gluteal muscles while minimally stressing the patellofemoral joint. exercises were limited to those in full extension and included isometric quadriceps setting, straight leg raise, hip abduction in supine and weight transference in standing (33,34).

exercises aimed to induce strength endurance with the player performing 20–25 repetitions of 3–5 sets with 1–2 minutes rest between sets (35). the exercises were performed daily to enhance learning and motor control.

Graded limb loading phase (3–8 weeks) this phase aimed to introduce graduated patellofemoral joint loading, restore normal range of movement, normalise gait pattern, early proprioceptive work and strengthen gluteal and quadriceps muscles. the criteria used to decide if the player was ready for progressive limb loading activity is reported below (table 3). the player actively achieved 0–120° by week 4 and full range of movement by week 6. gait was normalised quickly with education drills and the player had a good independent gait without aid by week 4. early introduction of exercise bike aided the return of flexion and enhanced cardiovascular fitness while placing low level forces through the patellofemoral joint (30).

Reduced knee flexion angle was used during closed chain exercises to minimise patellofemoral joint loading (36,37) while sufficiently activating the quadriceps and gluteal muscles for strength gains (38,39). by week 6 the player was pain-free controlling mini squats and wall squats in short ranges. Progression then occurred with the player moving through larger ranges and initiating unilateral mini squats to progress gluteal and quadriceps strengthening and increase patellofemoral joint forces (38).

Maintenance of dynamic alignment was of primary importance throughout all 31

rehabilitation exercises. Progressively single leg dissociation training ensued where the player would perform single leg squats but reach in different directions with his uninjured leg. the focus of this phase was to induce hypertrophy, therefore exercises were performed in 8–12 repetitions, 3 sets

with 1–2 minute rest periods 4 days per week (35). When the player could easily achieve 3 sets of 8–12 reps of the exercise then additional loading occurred, eg. weights, resistance bands and height (Figs 1, 2).

load acceptance training (8–12 weeks) Figure 1: Example exercise. Isometric wall squat. Subject stands with their back against the wall with their feet facing forwards. The subject then bends their knees to a small comfortable range and holds for 5–10 seconds. The subjects’ hip, knee and second toe should be in alignment. The subject then returns to the start position.

During the initial rehabilitation the knee angle should be no more than 50° to minimise patellofemoral joint stress.

Progressions: (1) Add a resistance band around the thighs to encourage gluteal activity and reduce knee valgus position. (2) Add dumb-bells in hands. (3) Increase the knee bend to increase patellofemoral joint stress at appropriate time.

a

b

Figure 2: An example exercise is the small-range knee extension against resistance band. The patient stands on one leg with a resistance band around the knee, flexed to approximately 30° (a). The patient then extends the knee to a straight position and holds for 5–10 seconds (b).

TaBle 3: crITerIa To ProGreSS To lImB loaDInG acTIvITY In order to progress to limb loading activity, the patient must meet the following criteria: n Achieve AROM 0–120° n control a bilateral squat to thighs parallel with even weight baring between limbs n Have effusion less than 1cm difference in the morning and with activity n Quadriceps activation (×10 reps single leg raise, no lag) n gluteal activation (×10 reps bridging to neutral) n Hamstring activation (×10 reps straight leg bridge on chair) n Normal symmetrical gait.

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In this phase, while progressing strengthening and work capacity training, load acceptance training started. the criteria used for this player to start training are shown below (table 4). exercises were progressed from bilateral through to unilateral load acceptance activities with all exercises performed through multiple planes of movement with increasing load and stability challenges prior to progression. jogging places forces of 7 times body weight through the patellofemoral joint (31) and was included when the player could control a single leg squat and a single leg hop with good dynamic alignment.

return-to-sport training (12 weeks+) the return-to-sport training phase aimed to develop the athlete’s work capacity to allow him to undertake his normal sporting role. the criteria used to allow the player to return to unrestricted sports training is shown below (table 5). strengthening work continued for maintenance as per previous phases. Load acceptance exercises were performed under fatigue and with random elements, eg. opponents and unpredictable changes of direction. training became more sport-specific with sprint and agility training a key part of the rehabilitation sessions.

Measurement tools the star excursion balance test (sebt) was used to assess dynamic stability and balance across multiple planes at week 8 and 12. sebt has been proposed as a reliable indicator of progress of dynamic postural and lower limb control in knee rehabilitation (40,41). Lower limb strength was determined through functional testing.

Hop testing was performed at week 12 as a measure of lower limb strength and to check landing mechanics. single hop for distance, triple hop for distance and cross over hop test have all been shown to be reliable measures of lower limb strength (42,43). t-test was selected as a criterion for return to sport as pre-season data was available for comparison, the test involves attributes that are regularly needed during football and has been sportEX medicine 2014;59(January):28-35

literature review

shown to be a reliable measure of agility (44). A qualitative scoring system (the Qualitative Analysis of single Leg squat or QAsLs) was used to identify suboptimal behaviour during a single leg squat and single leg landing and was performed weekly from week 6. the QAsLs shows excellent validity when compared to 3d kinematics for single leg squatting and landing (45), strong reliability when assessing in real time and during video analysis (46) and excellent intra and inter-tester reliability (46,47).

long-term management the player was given a maintenance programme of quadriceps and gluteal strengthening to perform through the season. Patellofemoral joint pain and instability would be continually monitored following his return to sport. control of single leg squat and single leg hop would be checked regularly.

If significant deficits in control were demonstrated then a discussion with the coach would occur to reduce game time and loading reducing risk of injury.

If further dislocation or subluxation occurred then the player may be a candidate for a MPFL reconstruction which reports a low re-dislocation rate of 0–10% (48).

reFlecTIon anD lImITaTIonS Overall effective rehabilitation occurred allowing the player to return to sport training in an acceptable time frame. clinical reasoning and justification throughout allowed appropriate application of modalities and loading. the most crucial part of this player’s injury was the initial management.

A large haemarthrosis was present which if managed poorly could have had significant effects on the player’s pain level, ability to activate muscle, progression through rehabilitation and ultimately return-to-sport time. However, this was managed and monitored well with the use of evidence-based modalities. On reflection additional modalities may have enhanced rehabilitation. during rehabilitation it was difficult to effectively measure strength changes as isokinetic testing or handheld dynamometry were not available. testing strength was determined by www.sportEX.net

TaBle 4: crITerIa To ProGreSS To loaD accePTance worK In order to progress to load acceptance work the patient must be able to meet the following criteria: n single leg squat to 90° with good control, 10 reps (QAsLs score 0–1) n single leg stand neutral, 45° and 90° flexion 10 second hold n sebt: within 10% of pre-season score n bilateral drop jump off 30cm bench (QAsLs 0–1) n gluteal capacity: single leg short lever bridge on box to 45° (hip), 25 reps n Hamstring capacity: single leg long lever raise on box to 45° (hip), 25 reps n calf capacity: single leg calf raise, 25 reps n Full range of movement n effusion: minimal activity-related effusion (<1cm change).

manual muscle testing, the ability to perform progressively more difficult tasks and through functional hop testing. during early rehabilitation, altering the motor component of AMI by using an electronic muscle stimulator while performing isometric quadriceps contractions and straight leg raise may have preferentially activated more type II muscle fibres and had a greater affect than exercise alone (49,50). When the knee was swollen, performing isometric quadriceps exercises where the intra-articular pressure is lowest (30–50°) might have allowed for maximum gains in activation of quadriceps, minimising the affects of atrophy (51). this was not performed as the player was immobilised in extension during this period. Limitations around bracing in extension for 3 weeks have been discussed earlier in this case report.

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by AdHeRINg tO stRIct cRIteRIA

TaBle 5: crITerIa For reTurn To unreSTrIcTeD SPorT TraInInG In order to return to unrestricted sport training the patient must meet the following criteria: n ROM at pre-injury level and equivalent to the other side n No gross patellofemoral instability n No joint effusion n No tenderness over the medial structures or MPFL n Hop test: single leg hop for distance and cross over within 95% contralateral side n sebt comparable to left and within normal values n t-test comparable to pre-season test.

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online If you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access. video: Patella dislocation in a football game (http://spxj.nl/1aySiP9) Courtesy of Youtube user cityclinic

FurTher reSourceS 1. traumatic patellar dislocation: traumatic patellar dislocation and clinical significance of medial patellofemoral ligament injury by Petri sillanpaa. lambert academic Publishing 2010. ISBn 3838300998.

2. sports Rehabilitation and Injury Prevention by Paul comfort and earle Abrahamson. wiley-Blackwell 2010. ISBn 0470985631 3. QAsL scoring tool for single leg loading. see: Herrington H, Myer g, Horsley I. task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary.

Physical Therapy in Sport 2013;14(4):188–198.

DISCUSSIONS

n How long should someone be immobilised following patella dislocation? n can you specifically recruit vastus medialis oblique? n should we treat first-time patella dislocations conservatively or surgically?

continuing education Multiple choice questions this article also has an eLearning test which can be found under the eLearning section of our website. tests from April 2013 onwards can be done on most digital devices.

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Th AuThoR ThE Sam graduated with a BSc in Physiotherapy from Keele university in 2008 and is currently in his final year of an MSc in Sports Injury Rehabilitation at the university of Salford.

Presently working in the NhS as a senior physiotherapist in Musculoskeletal outpatients and working for Wrexham Football Club as part of the Centre of Excellence. Since graduation developed a keen interest in musculoskeletal disorders, particularly of the lower limb. he has worked with many athletes across many different sports, but primarily football and tennis. Current research interests include patellofemoral pain, ACL rehabilitation, patella dislocation, MPFL reconstruction rehabilitation, posterolateral corner injuries of the knee and assessment of lower limb control.

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